Network Bulletin: September 2013 - Volume 57 network bulletin An important message from UnitedHealthcare to health care professionals and facilities UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information.* *Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law Table of Contents Click on any of the article titles below to go directly to the article you wish to read. Front & Center • UnitedHealthcare Medicare Solutions • • 2014 Medicare Advantage Service Area Reductions and Member Disenrollments • Member Outreach Program for Medicare Members Extends Reach • UnitedHealthcare Medicare Advantage Coverage Summary Updates • Concierge Medicine Practices Florida Providers Only: UnitedHealthcare Prior Authorization Requirement for Commercial Benefit Plans – Outpatient Injectable Chemotherapy • Announcing Neonatal Resource Services Guidelines • UnitedHealth Premium® Designation Assessment Update • IMRT Data Collection Forms Updated on UnitedHealthcareOnline.com • Optum Cloud Dashboard and Claim Reconsideration With Attachments Application are Here! UnitedHealthcare Reimbursement Policy • New Prior Authorization Requirement for Ventricular Assist Devices • • Health Benefit Exchanges • Preventive Care Update • Essential Health Benefits and Member Out-of-Pocket Update • 2 UnitedHealth Premium® Specialty Centers Program and Hospital Comparison Program – Status of Programs UnitedHealthcare Commercial ACP Depression Care Guide Now Available to Primary Care Providers • Administration of Routine Vision Benefits to Transition to Spectera • Register Now to Start Receiving Online Member Payments Network Bulletin: September 2013 - Volume 57 • UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates New Reimbursement Policy: Name Change for Physicians Billing Non-physician Health Care Professional Medicine Services Policy • Update Regarding Revision to the Physical Medicine and Rehabilitation: Speech Therapy Policy • Procedure to Modifier Policy Revised • Revision and Renaming of the Laboratory Rebundling Policy UnitedHealthcare Community Plan • Florida Providers Only: UnitedHealthcare Community Plan Prior Authorization Requirement for Outpatient Injectable Chemotherapy • Florida Providers Only: UnitedHealthCare Community Plan Change in Ambulatory Grouper Rates From 1-9 to 1-14 • For MississippiCAN and Mississippi CHIP Providers: UnitedHealthcare Community Plan Now Offers E-prescribing • Health Care Reform Medicaid PCP Increase Implementation Update For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Table of Contents Click on any of the article titles below to go directly to the article you wish to read. UnitedHealthcare Military & Veterans • • 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available – October 1, 2013 A Message From UnitedHealthcare Military & Veterans Program Integrity Team Doing Business Better • 3 Effective July 31, 2013: Change to DME Provider Network UnitedHealthcare Pharmacy • SignatureValue™ Benefit Interpretation Policy Updates • UnitedHealthcare Consolidated Pharmacy Benefit Program • UnitedHealthcare of the River Valley Preauthorization List and Policy Updates for Commercial and hawk-i Members Only • Synagis® (palivizumab) Procurement Process for the 2013-14 RSV Season Odds and Ends Clinical Update • Effective Dec. 1: Online Clinical Submissions to be Required • Clinical Practice Guidelines • Coordination of Care Between PCPs and Specialists • Cardionet Joins Network of Providers Offering Outpatient Cardiovascular Monitoring • Gordian Medical Technologies Joins Network of Medical Supply Providers UnitedHealthcare Affiliates • Health Management Programs • • Training Sessions for Electronic Solutions Neighborhood Health Partnership Prior Authorization Requirement – Outpatient Injectable Chemotherapy • Forms More Accessible Now on UnitedHealthcareOnline.com • Oxford Medical and Administrative Policy Updates • Electronic Inpatient Admission Notifications • SignatureValue™ Medical Management Guideline Updates Network Bulletin: September 2013 - Volume 57 • Optum Bank Offers Loans to Providers • UnitedHealthcare Adoption of Administrative Simplification Operating Rules for Electronic EFT and ERA • EPS Data Packages for Faster Downloads Now Available For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center UnitedHealth Premium® Specialty Centers Program and Hospital Comparison Program – Status of Programs UnitedHealthcare has made the decision to discontinue the UnitedHealth Premium® Specialty Centers program and the Hospital Comparison Program, effective January 1, 2014. When the programs end, we will no longer display specialty center designations or hospital quality and cost results on our consumer websites. We have notified facilities and hospitals impacted by these changes. Due to the voluntary nature of the UnitedHealth Premium Specialty Centers program, the number of facilities participating in the program has significantly diminished and the program is no longer ideal to support consumer display or tiered benefit product needs. need for the cost portion of the Hospital Comparison Program. Analysis is currently underway for hospital quality information sources to complement the cost information in consumer tools. Please contact us at 866-270-5588 or by e-mail at [email protected] (Specialty Centers Program) or [email protected] (Hospital Comparison Program) if you have any questions. The addition of inpatient facility cost information in the Health Care Cost Estimator has eliminated the 1 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Announcing Neonatal Resource Services Guidelines Each year Neonatal Resource Services (NRS), a division of Optum, which is part of UnitedHealthGroup, convenes an expert panel of neonatologists to review Optum’s clinical guidelines. At the April 2013 expert panel meeting, we reviewed evidence-based clinical guidelines for: neonatal sepsis, apnea and bradycardia, feeding, neonatal abstinence syndrome, thermoregulation, and discharge planning. The guidelines are used by our case managers and medical directors to optimize the neonatal intensive care unit (NICU) stay and are based on a review of relevant neonatal literature with a focus on key clinical milestones to ensure safe discharges. 2 Network Bulletin: September 2013 - Volume 57 You can find the new NRS guidelines by using the following links: • Apnea and Bradycardia • Discharge Planning • Feeding the Neonate • Neonatal Abstinence Syndrome • Neonatal Sepsis • Thermoregulation For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center UnitedHealth Premium® Designation Assessment Update Please watch for your 2014 Premium designation assessment results. Physicians and practice administrators who are in markets where the program is available and practice in one of the 26 Premium-eligible medical specialties will receive their results later this fall. Public designation display Time frame for claims data Prior to the public display of the assessment results on our consumer websites, we will provide ample time for you to review your assessment results and consider reconsideration, if applicable. Public designation display of the results will occur in 2014. The updated Premium designations are based on an updated methodology and a new time frame of paid claims (January 1, 2010 - February 28, 2013). Assessment reports To access your assessment results and review how your practice compares with national standards for quality and local specialty-specific cost efficiency benchmarks, visit UnitedHealthcareOnline.com and select “UnitedHealth Premium” on the top navigation bar. On the site you will find a Report User Guide to help get you started. Resources Go to UnitedHealthcareOnline.com and select “UnitedHealth Premium” on the top navigation bar. Here you will find resources and tools including the program’s methodology, FAQ, registration information and reconsideration materials. 3 Network Bulletin: September 2013 - Volume 57 New Specialties • General Surgery • General Surgery - Colon/Rectal • Ophthalmology • Ear Nose Throat (ENT) • Urology *Note: Infectious disease specialists will not be included in the 2014 Premium program. Notification has been sent to these physicians. Further Information: Go to UnitedHealthcareOnline.com and select “UnitedHealth Premium” on the top navigation bar to find resources and tools that explain the program. Or call 866-270-5588. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center IMRT Data Collection Forms Updated on UnitedHealthcareOnline.com Based on changes to UnitedHealthcare’s medical policy for Intensity Modulated Radiation Therapy (IMRT), we have updated the Intensity Modulated Radiation Therapy (IMRT) Data Collection Forms. The new forms can be found at UnitedHealthcareOnline.com > Clinician Resources > Cancer-Oncology > Intensity Modulated Radiation Therapy > Related Links. The most efficient way to submit a prior authorization for IMRT services is by completing the appropriate IMRT Data Collection Form, attaching relevant clinical information. IMRT cases submitted without a completed IMRT Data Collection Form may require additional review time. the necessary clinical information for a timely review. The initial submission of complete information using the UnitedHealthcare IMRT Data Collection Form benefits you and our members. If you have feedback regarding the IMRT Data Collection Form, please send an email to [email protected]. If we do not receive the necessary information, a coverage decision may be based on incomplete information. Submission of clinical records without a completed IMRT Data Collection Form rarely provides 4 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Optum Cloud Dashboard and Claim Reconsideration With Attachments Application are Here! Now you can use the Optum Cloud Dashboard website to submit reconsideration requests with attachments for Commercial, UnitedHealthcare Medicare Solutions, Oxford, UnitedHealthcare West and UnitedHealthcare Community Plan claims1. Later this year Optum Cloud Dashboard will become your gateway to UnitedHealthcareOnline.com. If you are a UnitedHealthcareOnline.com Standard User, ask your Password Owner (the person who approved your access to UnitedHealthcareOnline.com) or ID Administrator to register for Optum Cloud Dashboard and start your set-up process. Once the set-up is completed on your behalf, you will receive an email from [email protected] inviting you to complete your registration. For assistance, please refer to our Tips and the Standard User Quick Reference Guide. If you are a UnitedHealthcareOnline.com Password Owner or ID Administrator, it’s important that you register first for Optum Cloud Dashboard so that others in your practice or facility will be able to register. Get started by logging into UnitedHealthcareOnline.com and click User ID and Password Management. For assistance, please refer to our Tips and the Administrator Quick Reference Guide. Continued > 5 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Optum Cloud Dashboard and Claim Reconsideration With Attachments Application are Here! < Continued For more information about Optum Cloud Dashboard, click here. For assistance with registration, please call the Optum Cloud Support Center at 855-819-5909 (Monday through Friday, 7 a.m. to 9 p.m. CST) or email [email protected]. We are also offering webcast training sessions about Multi-TIN Access, Registration & Provider Managed Security and the Claim Reconsideration with attachments application. UnitedHealthcare and Optum, a leading information and technology-enabled health services business, are using cutting edge cloud technology to drive change and improvements in revenue cycle processes. Strategic collaboration between UnitedHealthcare and physicians, hospitals and other health care facilities allows testing of solutions that streamline and simplify the administrative experience. 6 Network Bulletin: September 2013 - Volume 57 If a state has specific provider dispute or appeal rights, then items received through Optum Cloud Dashboard will be handled and reported as a dispute or appeal, and appropriate acknowledgement and closure notices will be sent according to state requirement. The Optum Cloud Claim Reconsideration with attachments application is not yet available for: TRICARE West, UnitedHealthcare Plan of the River Valley, Inc. (Commercial and Community Plan) and UnitedHealthcare Community Plan of the District of Columbia, Kansas, Louisiana, Michigan and Nevada. 1 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center New Prior Authorization Requirement for Ventricular Assist Devices Effective for dates of service on or after January 1, 2014, UnitedHealthcare will implement a prior authorization requirement for Ventricular Assist Devices (VADs) for destination therapy and bridge-to-heart transplant indications for Commercial and Medicare Solution Members. Noncompliant services will not be eligible for reimbursement. Failure of physicians and facilities to obtain authorization or confirm that an approved authorization is on file prior to performing the procedure may result in claims being denied in whole or in part If you are denied reimbursement because of failure to obtain prior authorization, you may not balance bill our member. Additional information, including a list of VAD codes requiring prior authorization will be published in the November Network Bulletin. Please contact your UnitedHealthcare Network Management representative with any questions. Facilities are responsible for Admission Notification for inpatient services. UnitedHealthcare’s standard appeal process will apply to any denied claims. 7 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Health Benefit Exchanges As a requirement of the Patient Protection and Affordable Care Act (PPACA), the Health Insurance Marketplace, also known as Exchanges, must be operational in each state and accommodate member open enrollment on Oct. 1, 2013 for the 2014 plan year. The Health Insurance Marketplace is intended to make it easier for individuals and small businesses with fewer than 50 employees to compare plan offerings and buy health insurance from certified health insurers (Qualified Health Plans). The Health Insurance Marketplace is predicted to serve as a gateway for an estimated 29 million people to find health insurance. UnitedHealthcare is looking forward to the opportunity presented by the Health Insurance Marketplace and believes it will be a vibrant growth market that will have much to offer consumers. As we continue to evaluate opportunities and make decisions regarding our participation in the marketplace, we will provide notice on a state-by-state basis. While the marketplace will be the main method to purchase health insurance and enroll in public programs such as Medicaid and CHIP, people will also continue to get coverage from their employer, just as they do now. 8 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Preventive Care Update Under the Patient Protection and Affordable Care Act (PPACA), members in nongrandfathered health plans may receive certain preventive care services, based upon age, gender and other factors, without cost-sharing. These preventive services must be provided by physicians and health care professionals within the plan’s network. As a result, over the coming months, UnitedHealthcare will expand or change our coverage of certain preventive care services, including over-thecounter medication coverage, BRCA genetic testing for breast cancer and breast feeding supplies. Over-the-counter medication coverage The United States Departments of Labor, Health and Human Services, and the Treasury issued a series of Frequently Asked Questions (FAQs) earlier this year related to preventive care under PPACA. The FAQs clarified the Departments’ stance on covering certain over-the-counter (OTC) medications and contraceptives without cost-share when prescribed by a health care professional and filled at a network pharmacy. We are in the process of updating our systems to accommodate this change effective Nov. 1, 2013. UnitedHealthcare will cover certain OTC drugs and contraceptives for women, including aspirin, folic acid supplements for women, fluoride and iron supplements for children and vitamin D supplements for older adults. OTC contraceptives for women include female condoms and contraceptive film, foam and gel. The drugs on our new Preventive Care Medications List are covered at 100 percent when age- and gender-appropriate, prescribed by a health care professional and filled at a network pharmacy. Our revised Preventive Care Medications List will be ready Nov. 1, 2013 and posted on UHCWest.com and UnitedHealthcareOnline.com. Continued > 9 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Preventive Care Update < Continued BRCA genetic testing UnitedHealthcare covers BRCA genetic counseling and evaluation for BRCA testing today without cost-share as recommended by the current U.S. Preventive Services Task Force (USPSTF) and listed in our Preventive Care Services Coverage Determination Guideline. In April 2013, the USPSTF released a draft recommending the BRCA test for women over age 18 without a cancer history who may be at increased risk for BRCA-related cancer, as defined by their family history, nationality or other factors. In response to the USPSTF draft recommendation, UnitedHealthcare will cover the BRCA test without costshare beginning Oct. 1, 2013 for women over age 18 at risk for BRCA-related cancer and who have not been diagnosed with breast or ovarian cancer, subject to prior authorization. The test will be covered in full with prior authorization. As before, UnitedHealthcare will continue covering BRCA testing for women and men at risk with a history of cancer who meet other testing guidelines as provided by their benefit plan. UnitedHealthcare strongly recommends that women who believe that they should have the BRCA test done obtain genetic counseling. Breast-feeding supplies PPACA gives pregnant and postpartum women access to comprehensive lactation support and counseling and breast-feeding equipment without cost-sharing. Breastfeeding support, supplies and counseling must be received by a network provider, during pregnancy and/or in the postpartum period. Since many members may prefer to purchase a more portable and convenient electric breast pump rather than rent hospital-grade equipment (heavy-duty breast pumps designed for multiple users), effective Jan. 1, 2014, UnitedHealthcare will only cover the purchase of personal, double-electric breast pumps. In February 2013, the Health Resources and Services Administration (HRSA) guidelines related to breastContinued > 10 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Preventive Care Update < Continued feeding support were clarified to indicate that plans may cover the costs of purchasing, instead of renting, breastfeeding equipment without cost-share. Double-electric breast pumps often provide a better experience for the mother and help encourage breastfeeding because they are portable and more convenient. Studies also show that due to the variability in breast pumps, high-quality, personal use double-electric breast pumps are as effective as, or potentially more effective than hospital-grade pumps in outpatient settings.* UnitedHealthcare members who are renting a hospital-grade breast pump at the time of the Jan. 1, 2014 effective date may continue to do so. * Methods of milk expression for lactating women review by The Cochrane Collaboration, published in The Cochrane Library, 2011, Issue 12.s. . 11 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Essential Health Benefits and Member Out-of-Pocket Update The Patient Protection and Affordable Care Act (PPACA) requires insurers to provide coverage for an Essential Health Benefits (EHB) package in ten benefit categories, effective the first plan year on or after Jan. 1, 2014 for most Small Group (insured) and Individual policies. Three things to know about Essential Health Benefits: 1. All member cost share amounts for EHB must accumulate to the out of pocket maximum (OOPM), including deductibles, co-insurances and copays. Submitted claims and encounters must include member cost share amounts. Once the out of pocket maximum is met, there is no longer a need to collect cost share amounts including copays. For more information, visit UHC.com > United for Reform Resource Center > Health Reform Provisions > Essential Health Benefits 2. Most dental, vision and habilitative services will be covered under UnitedHealthcare medical plans affected by the EHB provision. State definitions of EHB will vary and may require product adjustments. 3. There are no annual dollar and lifetime dollar limits for eligible services. We removed lifetime dollar limits and annual dollar limits in 2010, and will continue to make any adjustments required as a result of each state’s determination of EHB. 12 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center ACP Depression Care Guide Now Available to Primary Care Providers At UnitedHealthcare, we know that primary care providers often are the first to recognize the signs of depression in patients. That’s why we want you to know about the American College of Physicians’ Depression Care Guide that is now available. 13 It offers concise, practical information and strategies to help busy clinicians reduce treatment gaps for depression in ways that suit your own practice setting. And for those who read the guide and respond to a 40-question quiz, there is an opportunity to qualify for: • Up to six AMA PRA Category 1 Credits™ - available until Dec. 15, 2014 to internists, family practitioners or psychiatrists • Up to six hours of AAPA Category 1 CME credits approved by the Physician Assistant Review Panel until Dec. 15, 2013 if you are a physician assistant • Continuing education available until Dec. 15, 2013. If you are a psychologist, consult with your local health care system, institution, or licensing board to determine if this course can be used to earn continuing education credit. Access to psychology licensing boards in the United States and Canada is available at: http://www.kspope.com/licensing/index.php. Network Bulletin: September 2013 - Volume 57 • Up to six continuing education contact hours approved by the Pennsylvania State Nurses Association and available until Dec. 15, 2013 if you are a registered nurse or nurse practitioner (this approval does not apply in Iowa and California.) The guide was created by a committee of 13 leading specialists in depression and is organized to help you readily access the specific topics that are most important to you, whether you are an internist, family practitioner, psychiatrist, psychologist, physician assistant, nurse practitioner, or nurse. The Depression Care Guide is free to all health care professionals and you do not need to be an ACP member to create an account. To access the guide, go to www.acponline.org and select “CME” from the drop-down menu, then “ACP Depression Care Guide”. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Administration of Routine Vision Benefits to Transition to Spectera UnitedHealthcare will begin to transition the administration of routine vision benefits to Spectera Eyecare Networks in 2014. Although this change will not happen all at once, it means that more patients with UnitedHealthcare medical plans will receive their eye care from Spectera Eyecare Networks doctors. Members will continue to use UnitedHealthcare network providers for medical vision benefits. Please include all appropriate diagnosis codes on your claims in order to accurately represent both medical and routine eye care encounters. The reason for the patient’s visit is a criteria for eye care coverage and claims payment. Be sure to verify eligibility and benefits at the time of service to be certain you are an in-network provider for each of your patient’s benefit plans. New coverage mandated by 14 Network Bulletin: September 2013 - Volume 57 the Affordable Care Act includes an annual eye exam and eyewear for pediatric patients. These patients will be directed to Spectera Eyecare Networks and you must be a contracted provider to provide this benefit. To request network participation with Spectera Eyecare Networks, please visit spectera.com/providers or call 800-638-3120. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Register Now to Start Receiving Online Member Payments UnitedHealthcare recently introduced a new online payment capability that allows commercial members to make online payments directly to physicians, hospitals and other facilities through the myuhc.com member portal to help you get paid faster and balance your accounts receivable. UnitedHealthcare has contracted with InstaMed, a leading Healthcare Payments Network, to process and distribute the payments directly to providers. InstaMed is certified and audited at the highest levels for both health care and payment processing by Payment Card Industry (PCI), Electronic Healthcare Network Accreditation Commission (EHNAC), and the Health Insurance Portability and Accountability Act (HIPAA). With online Member Payments, UnitedHealthcare commercial members manage and pay claims for their providers online from myuhc.com, a feature our members have told us they want. 15 Network Bulletin: September 2013 - Volume 57 Member Payments is an effective, efficient solution for providers and members. By registering with InstaMed to receive online member payments, you can enjoy: • Automatic payments deposited electronically into your preferred bank account • Faster payments to reduce accounts receivable balances • Reduced time and costs to collect payments • Payments posted automatically to a variety of practice management systems • Real-time payment reports available 24/7 • Increase payments and reduce bad debt by accepting a convenient patient payment method Continued > For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Front & Center Register Now to Start Receiving Online Member Payments < Continued There are no sign-up or monthly fees to register for Member Payments. As a registered provider, you pay a simple, flat rate that is similar to what you pay today when patients pay with their preferred payment cards or bank accounts. And if you are an existing provider on the InstaMed Payments Network, you’ll pay your current contracted fees. You can register for and get more information about online Member Payments at https://register.instamed.com/uhc or by calling 215-789-3682. InstaMed representatives will be available to help you with the registration process if you have questions. If you have additional questions, please contact your Physician or Hospital Advocate. 16 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Commercial Florida Providers Only: UnitedHealthcare Prior Authorization Requirement for Commercial Benefit Plans – Outpatient Injectable Chemotherapy Effective fourth quarter, 2013, UnitedHealthcare will require all Florida participating network providers to obtain prior authorization when administering chemotherapy drugs to UnitedHealthcare commercially insured members in an outpatient setting. Details on this protocol and how to obtain a prior authorization will be included in a future Network Bulletin and letters were sent to impacted providers. UnitedHealthcare uses the National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium™ in reviewing requests and making chemotherapy coverage decisions. 17 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Commercial UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates For complete details on the new and/or revised policies and guidelines listed in the following table, 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. Policy Title Policy Type Effective Date Policy Update Bulletin Chromosome Microarray Testing Medical Policy Oct. 1, 2013 Sept. 2013 Clinical Trials Coverage Determination Guideline Jan. 1, 2014 Sept. 2013 Clotting Factors and Coagulant Blood Products Drug Policy Oct. 1, 2013 July 2013 Aug. 2013 Sept. 2013 Cost Effective Quality of Care Guideline Quality of Care Guideline Aug. 1, 2013 July 2013 Anemia Drugs (Darbepoetin Alfa and Epoetin Alfa) Drug Policy Sept. 1, 2013 Aug. 2013 Botulinum Toxins A and B Drug Policy Oct. 1, 2013 Sept. 2013 NEW UPDATED/REVISED Continued > 18 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Commercial UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates Policy Title Policy Type Effective Date Policy Update Bulletin Chemotherapy Observation or Inpatient Hospitalization Utilization Review Guideline Aug. 1, 2013 July 2013 Durable Medical Equipment and Related Supplies, Prosthetics and Orthotics Utilization Review Guideline Aug. 1, 2013 July 2013 Gastrointestinal Motility Disorders, Diagnosis and Treatment Medical Policy Aug. 1, 2013 July 2013 High Frequency Chest Wall Devices Medical Policy Sept. 15, 2013 Aug. 2013 Human Immunodeficiency Virus (HIV) Tropism Testing Medical Policy Aug. 1, 2013 July 2013 Omnibus Codes Medical Policy Aug. 1, 2013 July 2013 Sept. 1, 2013 Aug. 2013 Panniculectomy and Body Contouring Procedures Coverage Determination Guideline Oct. 1, 2013 Sept. 2013 Pectus Deformity Repair Coverage Determination Guideline Oct. 1, 2013 Sept. 2013 Preventive Care Services Coverage Determination Guideline Aug. 1, 2013 July 2013 Oct. 1, 2013 Aug. 2013 Sept. 2013 Aug. 1, 2013 July 2013 Private Duty Nursing Coverage Determination Guideline Continued > 19 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Commercial Policy Title Policy Type Effective Date Policy Update Bulletin Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Coverage Determination Guideline Oct. 1, 2013 July 2013 Aug. 2013 Sept. 2013 Synagis (Palivizumab) Drug Policy Sept. 1, 2013 Aug. 2013 Medical Policy July 1, 2013 July 2013 REPLACED/RETIRED UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates 20 Transthoracic Echocardiography Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency or conflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy will prevail. Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare 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 member benefit plan documents, UnitedHealthcare medical 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 UnitedHealtcareOnline.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. 21 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Reimbursement Policy New Reimbursement Policy: Name Change for Physicians Billing Nonphysician Health Care Professional Medicine Services Policy The Physicians Billing Nonphysician Health Care Professional Medicine Services Policy name has been changed to the Nonphysician Health Care Codes Policy. As announced in the May 2013 Network Bulletin, effective for dates of services on or after Sept. 1, 2013, UnitedHealthcare has implemented a new policy denying reimbursement of nonphysician health care codes when reported by physicians. Supported by CPT coding guidelines, physicians should report evaluation and management (E/M) services (CPT codes 99201-99499) instead of the following medicine codes which are intended for use by nonphysician health care professionals: 22 Network Bulletin: September 2013 - Volume 57 • Medical genetics and genetic counseling services (CPT code 96040) • Health and behavior assessment/intervention (CPT codes 96150-96155) • Medical nutrition therapy (CPT codes 9780297804, HCPCS codes G0270-G0271) • Education and training for patient selfmanagement (CPT codes 98960-98962) For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Reimbursement Policy Procedure to Modifier Policy Revised – Additional Modifiers Being Added Update Regarding Revision to the Physical Medicine and Rehabilitation: Speech Therapy Policy An article published in the March Network Bulletin announced that the Physical Medicine and Rehabilitation: Speech Therapy Policy would be revised late in the second quarter of 2013 to deny reimbursement for CPT codes 9920199499 when reported by speech language therapists/pathologists. That policy change was delayed and will now be implemented in the third quarter of 2013. We apologize for any confusion caused by this delay. 23 Network Bulletin: September 2013 - Volume 57 Modifiers AU, AV, BA, BO, PT, and TH will be addressed through the revised Procedure to Modifier Policy and added to the Procedure to Modifier List. In accordance with correct coding, UnitedHealthcare will consider reimbursement for a procedure code/modifier combination only when the modifier has been used appropriately. The changes will occur in the fourth quarter of 2013. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Reimbursement Policy Revision and Renaming of the Laboratory Rebundling Policy To align with the Centers for Medicare and Medicaid Services (CMS) guidance related to qualitative drug screening codes, UnitedHealthcare will require the use of HCPCS codes G0431 and G0434 to report drug screen testing. We will no longer reimburse CPT codes 80100, 80101, and 80104 for these services. For more information on reporting these codes, please go to http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1105.pdf In addition, the Laboratory Rebundling Policy will be renamed as the Laboratory Services Policy, which more accurately reflects the services addressed in the policy. These changes will occur in the first quarter of 2014. 24 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Medicare Solutions 2014 Medicare Advantage Service Area Reductions and Member Disenrollments About five percent of our UnitedHealthcare Medicare Advantage members across the country will be impacted by service area reductions in 2014. These members will receive an official nonrenewal notice from UnitedHealthcare by Oct. 2, 2013. The non-renewal notice will give members information about their special election period eligibility for 2014 coverage and their Medicare Supplement guaranteed rights, as well as replacement plans for all Medicare Advantage organizations and Prescription drug plan sponsors available in their area. In most cases, these members will receive additional outreach by phone or mail to inform them of other health plan options offered by UnitedHealthcare. The majority of providers and facilities contracted for UnitedHealthcare Medicare Advantage products will 25 Network Bulletin: September 2013 - Volume 57 not be affected by these changes. In most areas, we will still offer networkbased Medicare Advantage plans, so provider contracts will remain in place. In markets where contracts are affected, UnitedHealthcare Network Account Managers will contact providers with more details. To learn more, please visit UnitedHealthcareOnline.com > Tools & Resources > Products & Services > Medicare > UnitedHealthcare Medicare, or contact your local Network Account Manager or Provider Advocate. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Medicare Solutions Member Outreach Program for Medicare Members Extends Reach Our outreach program focused on improving quality of care for our Medicare Solutions members has expanded and is now operating nationwide. Please note that you may see an increase in office visits due to this initiative. During telephone outreach calls, Optum health advocates and nurses educate members about preventive care, screenings and medication adherence. They encourage members to make doctor appointments to close their gaps in care and can even help members to arrange transportation to appointments. Our health advocates and nurses are trained to ask the questions that will help identify why the member has not sought care in an effort to provide them the specific information that they can best relate to. Our nurses can even answer some clinical questions. The multi-state initiative began in six states in the Northeast. 26 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Medicare Solutions UnitedHealthcare Medicare Advantage Coverage Summary Updates The following UnitedHealthcare Medicare Advantage Coverage Summaries were revised on June 24, 2013. A detailed summary of the updates is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Medicare Advantage Coverage Summary Updates: July 2013. Title Breast Reconstruction Following Mastectomy Cardiac Pacemakers and Defibrillators Dialysis Services Gastroesophageal and Gastrointestinal (GI) Services and Procedures Positron Emission Tomography (PET)/Combined PET-CT (Computed Tomography) Preventive Health Services and Procedures Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. 27 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Medicare Solutions Concierge Medicine Practices Physicians who have signed a standard UnitedHealthcare Physician Agreement have agreed to not engage in a concierge medicine practice. Additionally, page 76 of the Commercial and Medicare Advantage Administrative Guide, which is incorporated into the agreement, states the following: Additional fees for covered services Specifically, the agreement states the following: “You will not charge our customers anything for the services you provide, if those services are covered services under their benefit contract, but the applicable copay, coinsurance or deductible amount. If the services you provide are not covered under our customer’s benefit contract, you may bill our customer directly. You will not require a customer to pay a “membership fee” or other fee in order to access you for covered services (except for co-payments, coinsurance and/or deductibles provided for under the customer’s benefit contract) and will not discriminate against any customer based on the failure to pay such a fee.” 28 Network Bulletin: September 2013 - Volume 57 You may not charge our Customers fees for covered services beyond copayments, coinsurance or deductibles as described in their benefit plans. You may not charge our Customers retainer, membership, or administrative fees, voluntary or otherwise. This includes, but is not limited to, concierge/boutique practice fees. Lastly, CMS has published articles as well advising that “when participating providers request any other payment for covered services from Medicare patients they are liable for substantial penalties and exclusion from Medicare and other Federal health care programs.” For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Community Plan Florida Providers Only: UnitedHealthcare Community Plan Prior Authorization Requirement for Outpatient Injectable Chemotherapy Effective in the fourth quarter of 2013 UnitedHealthcare Community Plan will require all Florida providers administering chemotherapy on an outpatient basis to UnitedHealthcare Community Plan members in Florida to obtain prior authorization. Details on how to obtain prior authorization will be included in a future Network and letters sent to impacted providers. UnitedHealthcare’s drug policy which supports coverage based upon the National Comprehensive Cancer Network Drugs & Biologics Compendium™ will be used for coverage determination. 29 Network Bulletin: September 2013 - Volume 57 Florida Providers Only: UnitedHealthCare Community Plan Change in Ambulatory Grouper Rates from 1-9 to 1-14 UnitedHealthCare Community Plan has implemented the 1-14 payment group rates for ambulatory surgical centers (ASCs) effective September 1, 2013 for participating ASCs in Florida. This new rate is aligned with current Agency for Healthcare Administration (AHCA) reimbursement methodology. Should you have any questions, please feel free to contact your local Network Account Manager. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Community Plan For MississippiCAN and Mississippi CHIP Providers: UnitedHealthcare Community Plan Now Offers E-prescribing UnitedHealthcare Community Plan now offers e-prescribing for MississippiCAN and Mississippi CHIP, which allows prescribing physicians and other qualified health care professionals to electronically send prescriptions directly to a pharmacy from the place of service. The program provides the following advantages: 1. Added convenience. Instead of writing a paper prescription, a physician or other health care provider can enter the prescription directly into an electronic health record or practice management system using a secure network – the Pharmacy Health Information Exchange™ operated by Surescripts®. This program also allows physicians and other health care professionals to verify member eligibility, medication history, and check the list of covered medications prior to writing a prescription. 2. E-prescribing can help reduce preventable medication errors while optimizing members’ prescription drug benefits. A 2006 study from the Center for Information Technology Leadership estimates that electronic prescribing with clinical decision support has the potential to reduce preventable adverse drug events by more than 60 percent. Since it eliminates the need for handwritten prescriptions and phone and 30 Network Bulletin: September 2013 - Volume 57 fax communications between physicians and pharmacies, it can reduce the risk of having a prescription misinterpreted.* UnitedHealthcare’s e-prescribing program also automatically checks for potentially dangerous drug-to-drug and drug-allergy interactions. 3. E-prescribing provides physicians with tools to help prescribe the most clinically appropriate and cost-effective medication. More than 75 percent of community pharmacies in the U.S. currently accept e-prescriptions*.If the patient does not want his or her prescription sent electronically, or the pharmacy does not yet accept e-prescriptions, a health care provider can print the prescription for his or her patient. For more information, or to participate in UnitedHealthcare Community Plan’s e-prescribing program, please call Surescripts at 866-RxReady (866-797-3239). Thank you. Source: *http://www.cms.gov/Medicare/E-Health/Eprescribing/downloads/ e-rxreporttocongress.pdf For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Community Plan Health Care Reform Medicaid PCP Increase Implementation Update As of Aug. 1, 2013, the Centers for Medicare & Medicaid Services (CMS) confirmed that most Medicaid state agencies have the necessary approvals in hand to move forward with implementation of the Medicaid primary care physician (PCP) fee increase for the two-year period (Jan 1. 2013 – Dec. 31, 2014). 31 UnitedHealthcare Community Plan is working with its state Medicaid partners to properly and promptly implement the increased payments. Based on reimbursement methodologies established by your state’s Medicaid agency and approved by CMS, UnitedHealthcare Community Plan is working to implement the needed requirements to reimburse providers accordingly. As a reminder, this increase is available to participating and non-participating physicians and mid-level providers that follow the attestation process, as outlined by each state Medicaid agency. Note: All participating Medicaid state agencies have worked to implement their own repayment process with varying processes and requirements. Please visit your state’s specific UnitedHealthcare Community Plan provider page to learn more about implementation dates and details at UHCCommunityPlan.com or contact your local Physician Advocate or Network Account Manager. Be sure to review your state Medicaid agency’s website for PCP fee increase updates. UnitedHealthcare Community Plan continues to monitor all state activity and will provide updates as they are available. In most states, fee-for-service providers may either receive reconciled payment through transactional increases, per eligible claim submitted; or a lump sum payment at defined intervals throughout the two-year increase period. Capitated providers may receive reconciled capitation payments or another form of reimbursement for the eligible claims, as outlined by each state’s implementation process. Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Military & Veterans 2014 UnitedHealthcare Military & Veterans TRICARE Provider Handbook Available – October 1, 2013 The updated edition of the UnitedHealthcare Military & Veterans TRICARE Provider Handbook will be available on October 1, 2013. Changes in the Handbook will be effective on January 1, 2014 for currently contracted providers and immediately for providers contracted on or after October 1, 2013. The TRICARE Handbook is located on UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides, TRICARE Provider Handbook and UHCMilitaryWest.com > Providers > Provider Handbook. 32 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Military & Veterans A Message From UnitedHealthcare Military & Veterans Program Integrity Team Because UnitedHealthcare Military & Veterans is a federal contractor and not solely governed by its provider contracts and policies, we, along with our contracted providers, must comply with both general federal law and TRICARE regulations. Please be sure to familiarize yourself with TRICARE’s federal policies and procedures in addition to your provider contract with UnitedHealthcare Military & Veterans. UnitedHealthcare Military & Veterans’ Program Integrity Department provides the following programs to protect the ethical and fiscal integrity of TRICARE and educate beneficiaries and providers: • Health care fraud awareness programs • Easy methods for reporting health care fraud • Tools to help you understand health care fraud • Educational support if you are referred to TRICARE Management Activity’s Program Integrity Department for case prosecution. Please remember that health care fraud includes not only filing a TRICARE claim that is false or fictitious, but any intentional deception or misrepresentation by the provider and anyone acting on their behalf who either knew or should have known that the deception or misrepresentation could result in an unauthorized TRICARE payment (see 32 CFR §199.2). TRICARE’s definition of fraud is quite broad. Essentially it states that providers or anyone acting on their behalf will be held liable for fraud not only if they knew, but also if they should have known about the fraudulent activity. Continued > 33 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Military & Veterans A Message From UnitedHealthcare Military & Veterans Program Integrity Team < Continued TRICARE includes a subjective standard in its definition of fraud, ultimately increasing providers’ responsibility to report fraud to protect themselves from being held liable for an activity that the TRICARE Management Activity (TMA) determines you should have known might result in fraud. Below are some helpful tips on fully understanding your role as a TRICARE provider: 1. Read the TRICARE Provider Handbook, accessible at: https://www.uhcmilitarywest.com/ uhcmw/portal/provider/overview/ As a TRICARE contracted provider, you cannot bill TRICARE beneficiaries for anything other than their applicable deductibles, copayments and/or costsharing amounts. (see 32 CFR §199.6(a)(11)). 3. Promptly respond to any correspondence from UnitedHealthcare Military & Veterans’ Program Integrity Department. A point of contact is listed at the bottom of every correspondence from our department if you have any questions. The easiest way to report fraud is through our company website at: http://uhcmilitarywest.com and click on “Report Fraud, Waste, and Abuse”. 2. Do Not Balance Bill. Balance billing a TRICARE beneficiary for the difference between the amount TRICARE reimburses for a covered service and the amount that you charged is not permitted and may trigger a fraud investigation, recoupment or potential referral to TMA-PI for federal prosecution. 34 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Effective July 31, 2013: Change to DME Provider Network Philips Remote Cardiac Monitoring is no longer participating in UnitedHealthcare’s durable medical equipment (DME) provider network for all lines of business, effective July 31, 2013. Members who receive services provided by a non-network DME provider may incur higher out-of-pocket expenses, depending on their benefit plan. Please refer our members to in-network DME providers, as outlined in your network participation agreement. Services for cardiac monitoring and Home PT/INR can be obtained from the following nationally contracted providers: For cardiac monitoring services: 35 Network Bulletin: September 2013 - Volume 57 Biomedical Systems www.biomedsys.com Cardionet www.cardionet.com Lifewatch www.lifewatch.com For home PT/INR monitoring services: 800-877-6334 866-426-4402 877-774-9846 www.cardionet.com www.edgepark.com www.coaguchek.com 866-426-4402 800-321-0591 800-280-7801 Cardionet Edgepark Roche National and local providers for these services can be found at www.UnitedHealthcareOnline.com. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Cardionet Joins Network of Providers Offering Outpatient Cardiovascular Monitoring Cardionet, LLC has joined our network of providers offering outpatient cardiovascular monitoring, Holter monitors, event monitors and mobile cardiac outpatient telemetry to our members who meet clinical eligibility criteria across all lines of business effective July, 1, 2013. Cardionet also provides home PT/INR monitoring and testing. Nationally contracted cardiac monitoring providers are: For cardiac monitoring services: 36 Biomedical Systems www.biomedsys.com Cardionet www.cardionet.com Lifewatch www.lifewatch.com Nationally contracted PT/INR providers are: 800-877-6334 866-426-4402 877-774-9846 www.cardionet.com www.edgepark.com www.coaguchek.com 866-426-4402 800-321-0591 800-280-7801 Cardionet Edgepark Roche Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Gordian Medical Technologies Joins Network of Medical Supply Providers American Medical Technologies, dba Gordian Medical, has joined our network of medical supply providers effective July 1, 2013 for all lines of business. Gordian Medical provides wound care supplies such as gauze, tapes, and bandages to our members in long-term care nursing facilities and hospices. Nationally contracted medical supply providers are: Byram Edgepark Gordian Omnicare www.byramhealthcare.com www.edgepark.com www.amtwoundcare.com www.omnicare.com 877-902-9726 800-321-0591 800-568-5514 (Nursing home only) 800-990-6664 (Nursing home only) 37 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Health Management Programs UnitedHealthcare offers case and disease management programs to support physicians’ treatment plans and assist members in managing their conditions. Using medical, pharmacy and behavioral health claims data, our predictive model systems help us identify members who are at high risk and directs them to our programs. Patients can also be identified at time of hospital discharge via a Health Risk Assessment, Nurseline referral, or member or caregiver referral. If you have patients who are UnitedHealthcare members who would benefit from case or disease management, you can refer them to the appropriate program by calling the number on the back of the member’s health insurance ID card. Case Management Participation in these programs is voluntary. Upon referral, each member is assessed for the appropriate level of care for their individual needs. Programs vary depending on the member’s benefit plan. Specifically, our programs are designed to assist in ensuring individuals: At the core of case management is identifying high-cost, complex, at-risk members who can benefit from these services. We partner with members and their physicians or other health care professionals to facilitate health care access and decisions that can have a dramatic impact on the quality and affordability of their health care. • Receive evidenced-based care • Have necessary self-care skills and/or caregiver resources Continued > 38 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Health Management Programs < Continued • Have the right equipment and supplies to perform self-care • Have requisite access to the health care delivery system • Are compliant with medications and the physician’s treatment plan Depending on the member’s health plan and benefit plan design, disease management programs vary and may include: Our case managers are registered nurses who engage the appropriate internal, external or community-based resources needed to address members’ health care needs. When appropriate, we provide referrals to other internal programs such as disease management, complex condition management, behavioral health, employee assistance and disability. Case management services are voluntary and a member can opt out at any time. Disease Management Programs • Coronary Artery Disease • Diabetes • Heart Failure • Asthma • Chronic Obstructive Pulmonary Disease • Cancer • High Risk Pregnancy • Kidney Disease • Acute MI1 • Hemophilia1 1 Limited to eligible UHC River Valley and NHP members We offer disease management programs designed to provide members with specific conditions the appropriate level of intervention. Continued > 39 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Health Management Programs < Continued Our programs include: • Screening for depression and helping members access the appropriate resources. • Addressing lifestyle-related health issues and referring to programs for weight management, nutrition, smoking cessation, exercise, diabetes care and stress management. • Helping members understand and manage their condition and its implications. • Education on how to reduce risk factors, maintain a healthy lifestyle, and adhere to treatment plans and medication regimens. For some programs, members may receive: 40 • A comprehensive assessment by specialty-trained registered nurses to determine the appropriate level and frequency of interventions. • Educational mailings, newsletters and tools such as a HealthLog to assist them in tracking their physician visits, health status and recommended targets or other screenings. Network Bulletin: September 2013 - Volume 57 • Information on gaps in care and encouragement to discuss treatment plans, goals and results with the physician. Physicians with patients in moderate intensity programs may receive information on their patient’s care opportunities. • Transitional case management when high risk patients are discharged from a hospital • Outbound calls for the highest risk individuals to address particular gaps in care. You will be notified when patients are identified for the high-risk program. These programs complement the physician’s treatment plan, reinforce instructions you may have provided, and offer support for healthy lifestyle choices. For UnitedHealthcare Community Plan members: Please refer to the UHCommunityPlan.com Provider page to find your state-specific Provider Administrative Manual. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Doing Business Better Training Sessions for Electronic Solutions We offer instructor-led webcast training sessions to help automate and streamline administrative processes. • UnitedHealthcareOnline.com • UnitedHealthcareOnline.com Password Owner • UnitedHealthcareOnline.com Notification/ Prior Authorization Function Overview • Electronic Payments and Statements (EPS) • Electronic Data Interchange (EDI) 101 • OxfordHealth.com Overview • Post-n-Track® Demonstration • PNC Remittance Advantage for Electronic Oxford Payments and EOBs Click to learn more about UnitedHealthcare and Oxford sessions and obtain registration information. 41 Forms More Accessible Now on UnitedHealthcareOnline.com Session topics include: Network Bulletin: September 2013 - Volume 57 In response to feedback received on our annual electronic solutions survey, we’ve created a centralized forms section on UnitedHealthcareOnline.com > Tools & Resources > Forms. Here you’ll find all administrative, claim, patient, clinical and pharmacy forms. These forms also remain available in their previous locations. Electronic Inpatient Admission Notifications Use the Electronic Data Interchange (EDI) 278N to submit notifications from your practice management system for UnitedHealthcare, UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan. For more information, go to Admission Notification (278N), contact your clearinghouse/vendor or UnitedHealthcare at 888-804-0663 or [email protected]. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Pharmacy UnitedHealthcare Consolidated Pharmacy Benefit Program By a scheduled end date of January 2014, all pharmacy benefit services for our commercial members which are currently handled by Medco will be transferred to OptumRx. Consolidating our pharmacy services through OptumRx will help us to better partner with you and our members to improve health outcomes and better manage total health care costs. Prescription drug lists, benefit plan designs, specialty pharmacy and clinical programs will continue to be managed by UnitedHealthcare and members will continue to have access to more than 64,000 retail network pharmacies. This change will not require any action on your part or that of your patients and we will automatically transition information to OptumRx related to the these essential elements. You and Your Patients Most existing mail service prescriptions will transfer to OptumRx as well. Prescriptions for certain medications, like painkillers and expired prescriptions, will not transfer, and your patient will receive a letter from UnitedHealthcare instructing them to contact your office for a new prescription. Once your patients transition to OptumRx, you’ll find that the Online Prior Authorization tool at Continued > 42 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Pharmacy UnitedHealthcare Consolidated Pharmacy Benefit Program < Continued UnitedHealthCareOnline.com is easy to use. The majority of online prior authorizations are approved in real time, and an auto-population feature provides 95 percent of a member’s information. The OptumRx Prior Authorization team is also available by phone at 800-711-4555. benefits, the transition has been occurring in stages with completion expected by the end of January 2014. We’ve provided the schedule below (see chart, subject to change), but you may also want to ask patients to present their new ID card, which will contain the updated information. In addition to UnitedHealthcare’s commercial members, this change will apply to prior authorizations for Oxford, Medica, Harvard Pilgrim, River Valley and Neighborhood Health Plan. The Online Prior Authorization tool is available for these plans through OptumRx.com. For members of Health Plan of Nevada and Sierra Health & Life, please continue to use the current prior authorization process. Transition has been completed for: • UnitedHealthcare employees and select UnitedHealthcare commercial and Harvard Pilgrim members; • UnitedHealthcare commercial, Medica and Harvard Pilgrim members in the West and Northeast regions; If you e-prescribe through Sure Scripts, the NCPDP ID for OptumRx is #0556540. • UnitedHealthcare commercial, Medica and Harvard Pilgrim members in the Central region; and Timing Considerations • UnitedHealthcare commercial, Medica and Harvard Pilgrim national account customers across all regions. To ensure that members experience seamless service and access to the full range of covered pharmacy Continued > 43 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Pharmacy UnitedHealthcare Consolidated Pharmacy Benefit Program < Continued Transactions for the following are expected to be completed by end of January 2014: Date Region Plans • Sept. 1, 2013 - UnitedHealthcare commercial, Medica and Harvard Pilgrim members in the Southeast region. Jan. 1, 2013 • Oct. 1, 2013 - Oxford, Sierra, River Valley and Neighborhood Health Plan members in all regions. UnitedHealthcare Employees and Select Clients UnitedHealthcare Commercial, Harvard Pilgrim Apr. 1, 2013 West Region and Northeast Region UnitedHealthcare Commercial, Medica, Harvard Pilgrim June 1, 2013 Central Region UnitedHealthcare Commercial, Medica, Harvard Pilgrim July 1, 2013 National Account Clients Across all Regions UnitedHealthcare Commercial, Medica, Harvard Pilgrim Sept. 1, 2013 Southeast Region UnitedHealthcare Commercial, Medica, Harvard Pilgrim Oct. 1, 2013 All Regions Oxford, Sierra, River Valley, Neighborhood Health Plan Jan. 1, 2014 All Regions UnitedHealth One • Jan. 1, 2014 - UnitedHealth One members in all regions. • June 1, 2013 Central region UnitedHealthcare commercial, Medica, Harvard Pilgrim. • 44 July 1, 2013 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Pharmacy Synagis® (palivizumab) Procurement Process for the 2013-14 RSV Season Please remember that Synagis must be obtained from OptumRx Specialty Pharmacy, our contracted specialty pharmacy vendor for Synagis,* as described in the UnitedHealthcare Administrative Guide protocol for contracted providers. This is the same procedure required during the 2012-13 RSV season. OptumRx’s staff follows UnitedHealthcare’s drug policy criteria for Synagis and works directly with the Clinical Coverage Review unit to determine whether members meet clinical eligibility criteria for Synagis. Synagis should be obtained by using the UnitedHealthcare Specialty Pharmacy Services Enrollment Form for RSV. UnitedHealthcare’s Synagis policy reflects current recommendations from the American Academy of Pediatrics and its Committee on Infectious Diseases (COID). A copy of our drug policy is available at UnitedHealthcareOnline.com >Tools & Resources > Policies & Protocols >Medical & Drug Policies and Coverage Determination Guidelines > Synagis Policy. Enrollment forms are available at UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources and may be submitted directly to OptumRx by fax at 800-853-3844. UnitedHealthcare does not participate in MedImmune’s sponsored RSV Connection™ Program. We have contracted with OptumRx to work with physicians to collect our members’ clinical and eligibility information, and to provide a timely review of Synagis requests. Synagis requests for our members must be made through OptumRx Specialty Pharmacy for the 2013-14 RSV season. The most recently available RSV activity reports from state or local health departments or the Centers for Disease Control and Prevention)* should be submitted along with the enrollment form for requests Continued > 45 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Pharmacy Synagis® (palivizumab) Procurement Process for the 2013-14 RSV Season < Continued that include doses to be administered prior to Nov. 1, 2013 or after March 31, 2014. doses) which should provide coverage during the peak of the season, when prophylaxis is most effective.** In most of North America, peak RSV activity typically occurs between Nov. and March. As stated in our drug policy, palivizumab is unproven when administered: Benefit coverage is not available to UnitedHealthcare members for health services that we conclude are unproven. The National Respiratory and Enteric Virus Surveillance System (NREVSS) defines RSV national and regional season onset as the first of two consecutive weeks during which the mean percentage of specimens testing positive for RSV antigen is greater or equal to 10 percent and offset as the last of two consecutive weeks during which the mean percentage of positive specimens is greater or equal to 10 percent. • Out of season; • In doses greater than needed to provide protection in season; • In excess of five doses per single RSV season; • To persons other than those defined as high risk. Children who may qualify for the entire RSV season – including infants and children with chronic lung disease of prematurity or congenital heart disease or pre-term infants born before 32 weeks gestation - should receive palivizumab only during the five months following the onset of RSV season in their region (maximum of five 46 Network Bulletin: September 2013 - Volume 57 * This does not apply to the State of New York (Empire Plan). Additional Information: http://www.cdc.gov/rsv/index.html Reference: *. Centers for Disease Control and Prevention. Respiratory Syncytial Virus Activity — United States, July 2011–January 2013. MMWR. March 1, 2013 / 62(08);141-144. **American Academy of Pediatrics. Respiratory syncytial virus. In: Red Book: 2012 Report of the Committee on Infectious Diseases, 29th, Pickering LK. (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2012. For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Clinical Updates Effective Dec. 1: Online Clinical Submissions to be Required Optum™ Physical Health will require that all clinical submissions (Patient Summary Form, PSF-750) be submitted via the Optum website at www.myoptumhealthphysicalhealth.com effective Dec. 1, 2013. Participating providers will be notified 90 days prior to the online submission requirements effective date. PSF-750 forms received by fax will not be accepted and may result in delayed or denied payment. Contact Optum Provider Services at 800-985-3293 or 877-369-7564 with questions or to obtain your Provider ID and password. 47 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Clinical Update Clinical Practice Guidelines UnitedHealthcare uses evidence-based clinical guidelines from nationally recognized sources to guide our quality and health management programs. The following clinical practice guidelines are available at UnitedHealthcareOnline.com under Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Clinical Guidelines. Topic Organization Acute Myocardial Infarction with ST Elevation American College of Cardiology Foundation/American Heart Acute Myocardial Infarction without ST Elevation American College of Cardiology Foundation/American Heart Asthma National Heart, Lung and Blood Institute Attention Deficit Hyperactivity Disorder (ADHD) American Academy of Child and Adolescent Psychiatry Bipolar Disorder: Adults American Psychiatric Association Bipolar Disorder: Children & Adolescents American Academy of Child and Adolescent Psychiatry Cardiovascular Disease: Prevention in Women American Heart Association Cardiovascular Disease: Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and Other Atherosclerotic Vascular Disease American College of Cardiology/American Heart Association Cholesterol Management National Heart, Lung and Blood Institute Chronic Obstructive Lung Disease Global Initiative for Chronic Obstructive Lung Disease (GOLD) Continued > 48 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued Clinical Update Clinical Practice Guidelines Topic Organization Chronic Stable Angina American College of Cardiology/American Heart Association Depression/ Major Depressive Disorder American Psychiatric Association Diabetes American Diabetes Association Heart Failure American College of Cardiology/American Heart Association Hemophilia and von Willebrand Disease World Federation of Hemophilia and National Heart, Lung & Blood Human Immuno-deficiency Virus (HIV) HIV Medicine Association of the Infectious Diseases Society of America Hyperbili-rubinemia in Newborns American Academy of Pediatrics Hypertension National Heart, Lung and Blood Institute Preventive Services Agency for Healthcare Research and Quality Schizophrenia American Psychiatric Association/PsychiatryOnline Guideline Watch Sickle Cell Disease National Heart, Lung and Blood Institute Spinal Stenosis North American Spine Society Substance Use Disorders American Psychiatric Association/PsychiatryOnline This information is for general reference and not intended to address every aspect of a clinical situation. Clinical discretion should be used to interpret and apply this information to individual patients. If you do not have internet access and would like to obtain copies of a guideline, please contact our National Quality Management and Performance Team at 954-447-8818. 49 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Clinical Update Coordination of Care Between PCPs and Specialists Primary care physicians (PCPs) and specialists share responsibility for communicating essential patient information regarding consultations and referrals. When open communications does not occur consistently, it can affect providers’ ability to provide high quality care. According to a recent study*, there is a difference of opinion among providers regarding the frequency of information provided and received. Though more than two-thirds of PCPs said they send specialists notification of a patient’s history and the reason for the consultation all or most of the time, only a third of specialists said they routinely receive such information, according to the study. Meanwhile, more than 80 percent of specialists say they send consultation results to the referring physician all or most of the time, but only 60 percent of PCPs say they get that information. Relevant information from the PCPs includes Patient history and Diagnostic tests and results and the reason for the consultation. The specialist is responsible for communicating the consultation results and ongoing recommendations and treatment plans. Information exchange between providers should be timely, relevant and accurate to facilitate ongoing patient management. The partnership between PCPs and specialists is based on the consistent exchange of clinical information and this communication is a key factor in providing quality patient care. * Literature reference: Arch Intern Med. 2011 Jan Vol. 171 (1):56-65 . 50 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Affiliates Neighborhood Health Partnership Prior Authorization Requirement – Outpatient Injectable Chemotherapy Effective in the fourth quarter of 2013, the process to submit chemotherapy prior authorizations for members insured by Neighborhood Health Partnership will change. Details on how to obtain prior authorization will be included in a future Network Bulletin as well as letters to impacted providers. 51 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Affiliates Oxford Medical and Administrative Policy Updates For complete details on the new and/or revised policies listed in the table below, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Practical Resources > Medical and Administrative Policies > Policy Update Bulletin. Policy Title Policy Type Effective Date Policy Update Bulletin Custodial and Skilled Care Services Administrative Policy Aug. 1, 2013 July 2013 Implanted Electrical Stimulator for Spinal Cord Clinical Policy Aug. 1, 2013 July 2013 Interim New Product Coverage Criteria Clinical Policy Oct. 1, 2013 Sept. 2013 17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Clinical Policy Aug. 1, 2013 July 2013 Abnormal Uterine Bleeding and Uterine Fibroids Clinical Policy Aug. 1, 2013 July 2013 Abortions (Therapeutic and Elective) Clinical Policy Aug. 1, 2013 July 2013 Ampyra™ (Dalfampridine) Clinical Policy Aug. 15, 2013 July 2013 Aug. 2013 NEW UPDATED/REVISED Continued > 52 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates Oxford Medical and Administrative Policy Updates Policy Title Policy Type Effective Date Policy Update Bulletin Bilateral Procedures Policy Reimbursement Policy Jul. 1, 2013 Aug. 2013 Cardiology Procedures for CareCore National Arrangement Clinical Policy Oct. 1, 2013 July 2013 Aug. 2013 Sept. 2013 Cardiology Procedures Requiring Precertification Clinical Policy Oct. 1, 2013 July 2013 Aug. 2013 Sept. 2013 Cayston (Aztreonam for Inhalation Solution) Clinical Policy Aug. 15, 2013 July 2013 Aug. 2013 Diabetes Supply Coverage Clinical Policy Sept. 1, 2013 Aug. 2013 Diabetic Insulins Clinical Policy Aug. 1, 2013 July 2013 Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Policy Aug. 15, 2013 July 2013 Sept. 1, 2013 Aug. 2013 Aug. 1, 2013 July 2013 Aug. 15, 2013 July 2013 Aug. 2013 Sept. 1, 2013 Aug. 2013 Oct. 1, 2013 Sept. 2013 Drug Coverage Guidelines Clinical Policy Continued > 53 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates Oxford Medical and Administrative Policy Updates Policy Title Policy Type Effective Date Policy Update Bulletin Early Intervention Program/Birth to Three Clinical Policy Aug. 1, 2013 July 2013 Epidural Steroid and Facet Injections for Spinal Pain Clinical Policy Aug. 1, 2013 Aug. 2013 Gastrointestinal Motility Disorders, Diagnosis and Treatment Clinical Policy Sept. 1, 2013 Aug. 2013 Global Days Reimbursement Policy Jul. 1, 2013 Aug. 2013 Home Health Care Clinical Policy Aug. 1, 2013 July 2013 Hospice Care Clinical Policy Aug. 1, 2013 July 2013 Human Immunodeficiency Virus (HIV) Tropism Testing Clinical Policy Sept. 1, 2013 Aug. 2013 Increased Procedural Services Reimbursement Policy Aug. 1, 2013 July 2013 In-Network Exceptions for Breast Reconstruction Surgery Following Mastectomy Clinical Policy Aug. 1, 2013 July 2013 Inpatient Maternity Stay and Subsequent Home Nursing Administrative Policy Aug. 1, 2013 July 2013 Continued > 54 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates Oxford Medical and Administrative Policy Updates Policy Title Policy Type Effective Date Policy Update Bulletin Interferon Alphas Clinical Policy Aug. 15, 2013 July 2013 Aug. 2013 Lupron-Depot (Leuprolide Acetate) Clinical Policy Aug. 1, 2013 July 2013 Maximum Dosage Policy Clinical Policy Oct. 1, 2013 Aug. 2013 Sept. 2013 Moderate Sedation Policy Reimbursement Policy Sept. 1, 2013 Aug. 2013 Modifier Reference Policy Reimbursement Policy Aug. 1, 2013 July 2013 Obstetrical Policy Reimbursement Policy Sept. 1, 2013 Aug. 2013 Oxford's Outpatient Imaging Self-Referral Policy Clinical Policy Sept. 1, 2013 Aug. 2013 Precertification Exemptions for Outpatient Services Administrative Policy Aug. 1, 2013 July 2013 Preterm Labor: Identification and Treatment Clinical Policy Aug. 1, 2013 July 2013 Preventive Care Clinical Policy Aug. 1, 2013 July 2013 Oct. 1, 2013 Aug. 2013 Sept. 2013 Continued > 55 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates Oxford Medical and Administrative Policy Updates Policy Title Policy Type Effective Date Policy Update Bulletin Private Duty Nursing Clinical Policy Aug. 1, 2013 July 2013 Psychological and Neuropsychological Testing Clinical Policy Aug. 1, 2013 July 2013 Sodium Hyaluronate Clinical Policy Aug. 1, 2013 July 2013 Standing Systems Clinical Policy Aug. 1, 2013 July 2013 Time Span Codes Policy Reimbursement Policy Sept. 1, 2013 Aug. 2013 Transcatheter Heart Valve Procedures Clinical Policy Aug. 1, 2013 July 2013 Tysabri (Natalizumab) Clinical Policy Aug. 1, 2013 July 2013 Utilization Management Appeal Process and Timeframes for Connecticut Plans Administrative Policy Jun. 11, 2013 July 2013 Vaccines Clinical Policy Sept. 1, 2013 Aug. 2013 Vision Services Clinical Policy Sept. 1, 2013 Aug. 2013 Xolair (Omalizumab) Clinical Policy Aug. 1, 2013 July 2013 Note: The appearance of a service or procedure on 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 provided in this Bulletin and the posted policy, the provisions of 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. 56 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Affiliates SignatureValue™ Medical Management Guideline Updates For complete details on the new and/or revised policies listed in the table below, refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals. Policy Title Effective Date Policy Update Bulletin July 1, 2013 July 2013 Abnormal Uterine Bleeding and Uterine Fibroids July 1, 2013 July 2013 Chemotherapy Observation or Inpatient Hospitalization Sept. 1, 2013 Aug. 2013 Corneal Hysteresis and Intraocular Pressure Measurement July 1, 2013 July 2013 Diabetes Management Guidelines: Clinical Practice Guideline July 1, 2013 July 2013 Epidural Steroid and Facet Injections for Spinal Pain July 1, 2013 July 2013 Gastrointestinal Motility Disorders, Diagnosis and Treatment Sept. 1, 2013 Aug. 2013 Hepatitis Screening July 1, 2013 July 2013 High Frequency Chest Wall Compression Devices Sept. 1, 2013 Aug. 2013 NEW Implanted Electrical Stimulator for Spinal Cords UPDATED/REVISED Continued > 57 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates SignatureValue™ Medical Management Guideline Updates Policy Title Effective Date Policy Update Bulletin Human Immunodeficiency Virus (HIV) Tropism Testing Sept. 1, 2013 Aug. 2013 Omnibus Codes July 1, 2013 July 2013 Sept. 1, 2013 Aug. 2013 Panniculectomy and Body Contouring Procedures Oct. 1, 2013 Sept. 2013 Pectus Deformity Repair Oct. 1, 2013 Sept. 2013 Preterm Labor: Identification and Treatment July 1, 2013 July 2013 Preventive Care Services Sept. 1, 2013 Aug. 2013 Private Duty Nursing Sept. 1, 2013 Aug.2013 Rhinoplasty, Septoplasty, and Repair of Vestibular Stenosis July 1, 2013 July 2013 Sodium Hyaluronate July 1, 2013 July 2013 Surgical and Ablative Procedures for Venous Insufficiency and Varicose Veins Oct. 1, 2013 Aug. 2013 Sept. 2013 Transcatheter Heart Value Procedures July 1, 2013 July 2013 Aug. 1, 2013 Aug. 2013 REPLACED/RETIRED Transthoracic Echocardiography Note: The appearance 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 or conflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy will prevail. 58 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Affiliates SignatureValue™ Benefit Interpretation Policy Updates For complete details on the revised policy listed below, refer to the monthly SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals. 59 Policy Title Applicable State(s) Effective Date Policy Update Bulletin All (California, Oklahoma, Oregon, Texas and Washington) July 1, 2013 July 2013 UPDATED/REVISED Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Note: The appearance 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 or conflict between the information provided in this bulletin and the posted policy, the provisions of the posted policy will prevail. Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com UnitedHealthcare Affiliates UnitedHealthcare of the River Valley Preauthorization List and Policy Updates for Commercial and hawk-i Members Only For complete details on the new and/or revised policies and guidelines listed below, refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library. These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan membership only. They do not apply to members enrolled in a River Valley Ohio product or South Carolina product. 60 Policy Title Effective Date Policy Update Bulletin 17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P) Oct. 1, 2013 Sept. 2013 Benlysta (Belimumab) Oct. 1, 2013 Sept. 2013 Epidural Steroid and Facet Injections for Spinal Pain Oct. 1, 2013 Sept. 2013 Gastrointestinal Motility Disorders, Diagnosis and Treatment Nov. 1, 2013 Sept. 2013 Hereditary Angioedema (HAE), Treatment and Prophylaxis Oct. 1, 2013 Sept. 2013 Home Traction Therapy Nov. 1, 2013 Sept. 2013 Human Immunodeficiency Virus (HIV) Tropism Testing Oct. 1, 2013 Sept. 2013 Laser Therapy for Cutaneous Vascular Lesions and Pilonidal Disease Oct. 1, 2013 Sept. 2013 UPDATED/REVISED Network Bulletin: September 2013 - Volume 57 Continued > For more information call 877.842.3210, or visit UnitedHealthcareOnline.com < Continued UnitedHealthcare Affiliates UnitedHealthcare of the River Valley Preauthorization List and Policy Updates for Commercial and hawk-i Members Only Policy Title Effective Date Policy Update Bulletin Manipulative Therapy Oct. 1, 2013 Sept. 2013 Preventive Care Services Oct. 1, 2013 Sept. 2013 Private Duty Nursing Nov. 1, 2013 Sept. 2013 Standing Systems Oct. 1, 2013 Sept. 2013 Tysabri (Natalizumab) Oct. 1, 2013 Sept. 2013 Vaccines Oct. 1, 2013 Sept. 2013 Xolair (Omalizumab) Oct. 1, 2013 Sept. 2013 Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency or conflict between the information provided in this bulletin and the posted policy, the provisions of the posted policy will prevail. 61 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Odds & Ends Optum Bank Offers Loans to Providers Optum Bank offers financing to health care providers who are investing in new technology or equipment, expanding through real estate purchase or renovation, or need working capital. Optum Bank provides: Easy loan process Valuable consultation Get direct access to a loan officer. Closings can be arranged in providers’ offices. Find a loan application at optumbank.com. Financing specialists follow up 30 days after a loan closing and do annual reviews to monitor satisfaction. No-obligation consultations with financing and other experts are available to providers. The bank also offers optional $200 to $500 contributions to local health-related charities as a co-sponsor with providers. Fast follow-up Loan officers call providers back the same day they submit applications. The bank offers personalized service, face-to-face meetings and credit decisions based on providers’ schedules. Continued > 62 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Odds and Ends Optum Bank Offers Loans to Providers < Continued The bank’s lending services are particularly suited to small and mid-size providers. Optum Bank does not ask providers to make changes in their other banking relationships. For more information: Contact Nicholas Berger, senior loan officer, at [email protected] or 801-963-7230. Optum Bank is part of Optum, a division of UnitedHealth Group. 63 Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Odds and Ends UnitedHealthcare Adoption of Administrative Simplification Operating Rules for Electronic EFT and ERA UnitedHealthcare is implementing the following enhanced system and process changes effective Jan. 1, 2014, for CAQH/CORE Phase III Certification in compliance with the Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) required by the Department of Health and Human Services in compliance with the Health Insurance Portability and Accountability Act (HIPAA). For more information visit the Committee on Operating .Rules for Information Exchange (CORE) website at http://www.caqh.org/ORMandate_EFT.php. 64 Rule # Rule Name High-Level Requirements 350 Health Care Claim Payment/Advice (835) Infrastructure Rule • Specifies use of CAQH CORE Master Companion Guide Template • Requires entities to support Phase II CAQH CORE Connectivity Rule • Defines a dual-delivery (paper/electronic) to facilitate providers transitioning to electronic remits 360 Uniform Use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs): 835 Rule • Identifies a minimum set of four CAQH CORE-defined business scenarios with a maximum set of CAQH CORE- required code combinations that can be applied to convey details of the claim denial or payment to the provider 370 EFT & ERA Re-association (CCD+/835) Rule • Addresses provider receipt of the CAQH CORE-required Minimum Automated Clearing House (ACH) CCD+ Data Elements required for re-association • Addresses elapsed time between the sending of the v5010 835 and the CCD+ transactions • Requirements for resolving late/missing EFT and ERA transactions • Recognition of the role of NACHA Operating Rules for financial institutions 380 EFT Enrollment Data Rule • Identifies a maximum set of standard data elements for EFT enrollment • Outlines a “straw man” template for paper and electronic collection of data elements • Requires health plan to offer electronic EFT enrollment 382 ERA Enrollment Data Rule • Identifies a maximum set of standard data elements for ERA enrollment • Outlines a “straw man” template for paper and electronic collection of data elements • Requires health plan to offer electronic ERA enrollment Network Bulletin: September 2013 - Volume 57 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com Odds and Ends EPS Data Packages for Faster Downloads Now Available If you use Electronic Payments and Statements (EPS) to retrieve claims remittance information, now you can make that process quicker with new “data bundle” downloads. Log into EPS at optumhealthfinancial.com, and you can request ZIP files that will bundle data from one or more payers for the date or date range you select. Up to 13 months of 835s and EPRAs are available. Limited MEOB data is available, but those files will build over time until 13 months of back data is available, too. You can choose which data to include, such as: 835 remittance information, electronic proprietary remittance advice (EPRA) and/or multiple explanations of benefits (MEOBs). Most data requests will be ready for download within one to two hours. You will receive an email notifying you when your data file is available on the EPS website so you can log in and retrieve it. The data packages are available by logging into EPS at optumhealthfinancial.com. They are not available if you log into EPS through UnitedHealthcareOnline.com. Data files will be stored on the website for seven days and then deleted. If you don’t download files within the time allotted, you can return to the website and request a new download. 65 Network Bulletin: September 2013 - Volume 57 In addition, we now will send just one email per day to notify you that one or more claims payments have been deposited into your account, rather than multiple notifications. More information on EPS enhancements can be found in the “News” section on the EPS “Bulletin Board.” For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
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