Network Bulletin: January 2015 network...
Transcript of Network Bulletin: January 2015 network...
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
network bulletinNetwork Bulletin: January 2015
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2
Table of Contents
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2 Network Bulletin: January 2015
To save you time as you go about your busy day, you can click on any of the articles below and be taken directly to that article. You can also return to the Table of Contents from any page in the Network Bulletin by simply clicking “Table of Contents” in the top, right-hand corner of any page.
Front & Center
• UnitedHealthcare to Begin Publishing theNetwork Bulletin Monthly in 2015
• 2015 UnitedHealthcare Administrative Guide Available – Effective April 1, 2015
• HysterectomyPriorNotificationRequirements, Effective April, 6, 2015
• New Requirement for Immunoglobulin Infusion Therapy
• Sinuplasty Procedures to be Added to PriorAuthorization List on April 6, 2015
• LaboratoryBenefitManagementProgramUpdate
• Elect Your Payment Method in 2015
• Prior Authorization and AdvanceNotificationRequirementReminders
• HEDIS® 2015 Data Collection for UnitedHealthcareCommercial, Medicare and Medicaid Plans
UnitedHealthcare Medicare Solutions
• UnitedHealthcare Medicare AdvantageCoverage Summary Updates
UnitedHealthcare Commercial
• UnitedHealthcare Medical Policy, Drug Policy,Coverage Determination Guideline andUtilization Review Guideline Updates
• RadiologyandCardiologyNotification/PriorAuthorization Protocols for the State of Rhode IslandEffective Feb 1, 2015 – Training Opportunity
UnitedHealthcare Community Plan
• ImportantChangesinAdvanceNotificationand Prior Authorization Requirements
• Medical Policy & CoverageDetermination Guideline Updates
• Changes to the Cardiology Prior AuthorizationProtocol for Rhode Island MedicaidMembers Effective Feb. 1, 2015
UnitedHealthcare Commercial Reimbursement Policy
• New“X”ModifiersandImpacttoUnitedHealthcare CommercialReimbursement Policies
UnitedHealthcare Military & Veterans
• Introducing a New Civilian Referral Request Form
Doing Business Better
• Enhanced HIPAA Claim EditsPlanned for February 2015
• UnitedHealthcare Medicare SolutionsCoinsurance Calculation Reminder for Providers
• Coverage Determinations andUtilization Management Decisions
UnitedHealthcare Affiliates
• UnitedHealthcare of the River ValleyPreauthorization List and Policy Updates
• SignatureValue™BenefitInterpretation Policy Updates
• SignatureValue™ Medical ManagementGuideline Updates
• Oxford® Medical and AdministrativePolicy Updates
• UnitedHealthcare Negotiates National Contractwith Medway Air Ambulance, Inc. for Fixed-Wing Air Ambulance Services
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com33 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
The Network Bulletin will move from a bimonthly to monthly publication beginning with this issue. The Bulletinwillnowbeavailableonthefirstbusinessdayof every month.
The transition to the monthly Bulletin means you will receive the information you need from us in a timelier manner. And you will seeasignificantreductionofcontentineachedition,makingitamore user-friendly resource as you go about your busy day.
The monthly Bulletin is a direct result of your input. We appreciate your suggestions and welcome any additional ideas on how we can best communicate with you.
Please email us at [email protected] with any questions or feedback.
UnitedHealthcare to Begin Publishing the Network Bulletin Monthly in 2015
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com44 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
The Guide contains some important changes you will want to review. The following list is a high level summary of selected updates to the Guide; it is not intended nor should it be interpreted to represent every update or the details of any update. Please refer to the Guide for the complete text and detailed updates.
This essential resource for physicians, hospitals, facilities and other health care providers is now posted on UnitedHealthcareOnline.com > Policies, Protocols and Guides.
New in the 2015 Guide
• Electronic Payments and Statements (EPS) with new Virtual Card Payment Options (VCPs) – process for electronicfundstransfer/remittanceadvice.Ifyoucurrently receive paper checks and remittances, you will have a choice of direct deposit or VCP in 2015.
• Medicare Advantage Referral Required Product – newbenefitguidelinesaddedforMedicare Advantage members.
• Therapeutic radiation (IMRT, SRS, SBRT) Prior Authorization Program – new outpatient Prior Authorization requirement for Medicare Advantage members.
Revised in the 2015 Guide
• Optum Cloud Dashboard – Our cloud-based website offers three primary applications: Claim Reconsideration (with or without attachments), Benefits&Eligibility,andClaimsManagement.
• Expansion of Commercial and Health Insurance Marketplace Products – new product offerings to support the Commercial and Health Insurance Marketplacebenefitplans.
• Specialty Drug Prior Authorization for Medical Benefits (for Commercial Members) – now online at UnitedHealthcareOnline.com > Clinician Resources > Specialty Drug > Commercial Specialty Drug Prior Authorization Program.
• Discontinued Part B Specialty Drug Prior Authorization Program – requirement for Medicare Advantage members.
• NeighborhoodHealthPartnershipPrecertificationList – now online at myNHP.com > Providers > References > Utilization Management Protocols > Prior Authorization Process (protocol III).
• Charging Members for Non-Covered Services – changes to this protocol only apply to Medicare Advantage members.
• Providing advance notice to Commercial members for non-participating providers.
Please contact your Network Management representative, Physician Advocate, or Hospital & Facility Advocate for a printed copy of the UnitedHealthcare Administrative Guide.
* Except as otherwise noted, the new Guide is effective on April 1, 2015 for currently participating providers, and effective immediately for new participating provider on or after Jan. 1, 2015.
2015 UnitedHealthcare Administrative Guide Available – Effective April 1, 2015*
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
TheAmericanCongressofObstetriciansandGynecologists(ACOG)hasidentifiedthepreferred method for hysterectomies to be vaginal. Per ACOG, “evidence demonstrates that, in general, vaginal hysterectomy is associated with better outcomes and fewer complications than laparoscopic or abdominal hysterectomies.”
To align with ACOG’s recommendation and provide better outcomes for our members, UnitedHealthcare and UnitedHealthcare West Commercia and Medicare Planswill require prior authorization for certain hysterectomy procedures starting April 6, 2015. The following table lists the impacted codes:
Vaginal hysterectomies done on an outpatient basis do not need prior authorization. Failure to complete the prior authorization process will result in an administrative claim denial. Members cannot be billed for claims that are administratively denied.
A clinical denial will be issued, and a prior authorization number will not be issued, if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria. Upon issuance of a clinical denial, the member and provider will receive denial notices with the appeal process outlined. Appeals for clinical denials will be conducted by UnitedHealthcare.
The member cannot be billed for services we determined to be medically unnecessary unless the member, with the knowledge of our determination, agrees in writing to be responsible for the cost of the services.
If you have questions regarding these requirements, please contact your UnitedHealthcare market medical director or Physician Advocate.
HysterectomyPriorNotificationRequirements,Effective April, 6, 2015
Abdominal hysterectomy
Laparoscopic hysterectomy
Vaginal hysterectomy
Laparoscopic assisted vaginal hysterectomy
58150 58541 58260 58550
58152 58542 58262 58552
58180 58543 58263 58553
68.3 58544 58267 58554
68.39 58570 58270 68.51
68.4 58571 58275
68.49 58572 58280
58573 58290
68.31 58291
68.41 58292
58293
58294
68.5
68.59
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Effective Feb. 1, 2015, UnitedHealthcare will review the medical necessity of the site of service in additiontopriorauthorizationreviewforbenefitcoverageofimmunoglobulininfusiontherapy.
• For UnitedHealthcare Commercial plan and Mid-Atlantic members: Immunoglobulin prior authorization with medical necessity review will be required for your patients who receive outpatient facility infusion services. Based on the outcome of that review, you may need to switch patients to an alternative site of service for them to continue to receivebenefitcoverage.
• For UnitedHealthcare Oxford members: Members who use outpatient infusion services for immunoglobulin therapy are already subject to medical necessity review. Additionally, for those infusion services that are administered in a home care setting, these services will continue to require precertificationtoestablishthemedicalnecessity of the home care service.
• For UnitedHealthcare River Valley members: Members who use outpatient infusion services for immunoglobulin therapy are already subject to medical necessity review.
Failure to complete the new process prior to administering infusion services for immunoglobulin therapy will result in claims denial. Providers cannot bill members for services that are denied due to lack of prior authorization.
For more information about the requirement for immunoglobulin infusion therapy:
• UnitedHealthcare Commercial: Refer to the Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for Commercial and Medicare Advantage Products under the Specialty Drug Prior Authorization process found on UnitedHealthcareOnline.com > Clinician Resources > Specialty Drugs> Commercial Specialty Drug Prior Authorization Program.
• UnitedHealthcare of the Mid-Atlantic: Information about our evidence-based medical polices is available at UnitedHealthcareOnline.com > Clinician Resources > Specialty Drugs> Commercial Specialty Drug Prior Authorization Program.
• UnitedHealthcare Oxford: Information is available at OxfordHealth.com > Providers > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policies.
• UnitedHealthcare of the River Valley: Information is available at UHCRiverValley.com > Providers > Coverage Policy Library > Services requiring preauthorization.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com77 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Effective April 6, 2015, UnitedHealthcare Medicare Advantage and Commercial plans will require prior authorization for nasal sinus endoscopy procedures for patients 12 years and older who havefailedtohaveoneormoreofthefollowingmedicaltreatments:nasallavage,antibioticsand/or corticosteroids. The procedure is not proven for patients younger than 12.
The following is a list of impacted codes:
Failure to complete the prior authorization process will result in an administrative claim denial. Members cannot be billed for claims that are administratively denied.
A clinical denial will be issued, and a preauthorization number will not be issued, if it is determined during the clinical coverage review process that the service does not meet medical necessity criteria. Upon issuance of a clinical denial, the member and provider will receive a denial notice with the appeal process outlined. Appeals for clinical denials will be conducted by UnitedHealthcare.
The member cannot be billed for services we determined to be medically unnecessary unless the member, with the knowledge of our determination, agrees in writing to be responsible for the cost of the services.
If you have questions regarding these requirements, please contact your UnitedHealthcare market medical director or Physician Advocate.
Sinuplasty Procedures to be Added to the Prior Authorization List on April 6, 2015
CPT Code Procedure description
31295 Nasal/sinusendoscopy,surgical;withdilation of maxillary sinus ostium (eg, balloon dilation), transnasal
31296 Nasal/sinusendoscopy,surgical;withdilation of frontal sinus ostium (eg, balloon dilation) or via canine fossa
31297 Nasal/sinusendoscopy,surgical;withdilation of sphenoid sinus ostium (eg, balloon dilation)
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
TheUnitedHealthcareLaboratoryBenefitManagement Program started Oct. 1, 2014. This new program is designed to help improve quality of care and support appropriate utilization for outpatient laboratory services. The pilot launch is for laboratory services for fully insured UnitedHealthcare Commercial members in Florida, excluding Neighborhood Health Partnership. UnitedHealthcare previously communicated that claims impact related to the program would go into effect on Jan. 1, 2015. We have been closely monitoring progress ofthispilotprogramandaremakingrefinementsbasedondata, experience and input. We appreciate the constructive feedback we have received regarding the Laboratory BenefitManagementProgram.Theprogramremainsineffect; however, as a result of this input, we will initiate claims impact on a delayed schedule to be effective in the near future. We will notify you 30 days prior to initiating claimsimpactassociatedwiththeLaboratoryBenefitManagement Program.
In addition, we will be implementing additional Medical Policies and a revised Administrative Protocol starting Apr.1,2015,aspartoftheLaboratoryBenefit Management Program.
The updated program requirements will be posted by Jan 1, 2015 at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > UnitedHealthcare Laboratory Benefit Management Program.
Please contact your UnitedHealthcare Provider Advocate if you have questions or feedback as you begin implementing the program in your practice.
LaboratoryBenefitManagementProgramUpdate
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
UnitedHealthcare continuously looks for ways to simplify administrative processes, reduce administrative costs and accelerate access to the information network providers need. Optum’s Electronic Payments and Statements (EPS) is a free electronic funds transfer (EFT) and electronic remittance advice (ERA) service brought to you by UnitedHealthcare. It is the standard forreceivingUnitedHealthcarepaymentsandexplanationofbenefits(EOBs).EPSdeliverselectronicpaymentsdirectlytoproviders’specifiedbankaccount(s)andprovidesonlineEOBsto physicians, hospitals, other health care professionals and billing companies. In 2015, a Virtual Card Payment option will be added.
Paper, mail and tracking fees are a major expense within the health care industry. If all payers and providers move to electronic payments and EOBs, the health care industry could save $860 million. Currently, the Centers for Medicare and Medicaid Services (CMS) requires new applicants to leverage electronic payments as part of their credentialing process.
In support of positive industry trends, all existing and new UnitedHealthcare-contracted providers, who have not yet enrolled in EPS, must elect their preferred electronic claim payment method in 2015. Contracted providers can opt to receive payments directly to their bank account or through Virtual Card Payments. Virtual Card Payments are a secure electronic payment method that does not require your bank account information. Providers will receive reminders regardingfinalpaymentmethodelectiondeadlinedates90days prior to those deadline dates. If your organization does not elect either direct deposit (ACH) or Virtual Card Payments by your payment election deadline, your election will default to Virtual Card Payments and your organization will begin receiving Virtual Card Payments.
If your business operations require continued paper payments, please contact UnitedHealthcare after April 1 and prior to your payment election deadline. Further information will be provided by email.
Features of EPS with direct deposit or Virtual Card Payments:• ReceivepaymentsandEOBsfivetosevendaysfaster
than with paper
• Multiple claim payments generated in one day for thesame payer are combined into one deposit or VCPand one electronic EOB for easy reconciliation
• Simplifiedprocessingandreconciliation–automatepaymentpostingusingthe835/ERAorcontinuewith your existing paper process using our EOBprinting options
• Printeitherasingleconsolidatedfile(lesspaper)containing all EOBs for a given deposit or printindividual EOBs to submit to other carriers for yoursecondary claim submissions
• EOBs are available for 13 months and can bedownloadedasPDFfilestostoreonyourownsystem
• Reduced risk of lost, misrouted and stolen checks
Elect Your Payment Method in 2015
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Elect Your Payment Method in 2015
• Potential elimination of bank lockbox fees
• Practice management software and technical expertiseare NOT required.
• You can post payments the same way you do today
EPS Registration
To learn more about EPS, visit UnitedHealthcareOnline.com and select Electronic Payments and Statements under Quick Links on the home page. You can register for EPS with direct deposit any time, online or send us a completed enrollment form.
Enrollment for Virtual Card Payments will be available beginning in April 2015.
If you have questions about EPS, direct deposit, Virtual Card Payments or enrollment, call us at 866-842-3278 and select option 5, to speak with an EPS representative.
1 You acknowledge that that by processing a Virtual Card payment, you are subject to the terms and conditions governing card processing between you and your card service processor and that you are responsible for any charges and related third party fees, including interchange, merchant discount, or other card processing fees that may be imposed as a result of processing a Virtual Card payment through a card processor.
EPS with direct deposit: • No credit card processing fees• While funds are deposited to your
account, UnitedHealthcare will not debit or deduct claim adjustments from your checking or savings account. You can also contact your bank to ensure that you have appropriately placed controls over the electronic funds transfers to and from your account.
EPS with Virtual Card Payments:• Virtual Card Payments can
be processed using the same method leveraged by your organization to process credit card transactions. Please note, your current credit card processing fees will apply. Please confirmthoserateswithyourbank of choice directly.[2]
• Banking information is not shared outside your organization.
Posting and balancing with direct deposit:
1. Receiveemailnotificationswhenpayments are deposited to your designated bank account(s).
2. View the amount of the deposit and all EOBs associated with that deposit by logging on to EPS.
3. View or print EOBs and post payments manually to your practice management system, or auto-post using the free electronic remittance advice835/ERA.
Posting and balancing with Virtual Card Payment:
1. Your practice will receive a virtual card number in the mail and this card number should be retained in a secure location as you will need it for future payments. You willbenotifiedviaemailofnewclaim payments.
2. Redeem payments using the “card not present” transaction on your credit card terminal.
3. View or print EOBs and post payments manually to your practice management system, or auto-post using the free electronic remittance advice 835/ERA.
1 CAQH“2013U.S.HealthcareEfficiencyIndexElectronicAdministrativeTransaction Adoption and Savings.” Caqh.org. Revised May 5, 2014. Web. 16July2014.<http://caqh.org/EfficiencyIndex.php>.
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Effective for dates of service on or after Jan. 1, 2015, certain services have changed from theadvancenotificationorpriorauthorizationrequirementsfortheUnitedHealthcareandUnitedHealthcare West Commercial and Medicare Advantage Plans.
Orthopedic Procedures is a new category that will be added effective April 6, 2015 for UnitedHealthcare and UnitedHealthcare West Commercial and Medicare Advantage Plans. This new category will encompass Spinal Surgeries, Joint Replacements, and Hip Surgery.
The most up-to-date list of procedures requiring Advance NotificationorPriorAuthorizationfor:
• UnitedHealthcare Commercial can be found at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification.
• UnitedHealthcare and UnitedHealthcare West Medicare Advantage Plans can be found at UnitedHealthcareOnline.com > Clinician Resources > Advance & Admission Notification.
• UnitedHealthcare Community Plans can be found at UHCCommunityPlan.com > For Health Care Professionals > Select your State.
PriorAuthorizationandAdvanceNotification Requirement Reminders
Service Category(Effective Date)
Applies to Eliminated Codes
Added Codes
Orthopedic Procedures(April 6, 2015)
Commercial 29914
Medicare 29915
Community 29916
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
HEDIS® 2015 Data Collection for UnitedHealthcare Commercial, Medicare and Medicaid Plans
UnitedHealthcare is required to collect Healthcare Effectiveness Data and Information Set (HEDIS) information annually from our participating care providers for our Commercial, Medicare and Medicaid members. Our network must, therefore, provide requested medical record information so we can comply with the Centers for Medicare & Medicaid Services (CMS), state and federal regulators and accreditation organization requirements. HEDIS data collection takes place from February to May. We are grateful for your collaboration in this effort.
The following are key facts about the HEDIS data collection process:• HEDIS results are used to evaluate clinical care
performance, help ensure health plan members receive their recommended services, and measure health outcomes. The results are also used to support quality improvement and chronic condition improvement programs required by CMS.
• TheindicatedHEDISyearreflectstheyearthedatais collected rather than the year the care was given. For example, for the HEDIS 2015 cycle, we collect data for services rendered in 2014 or earlier. Medical records for services rendered in 2015 are not included in that data collection cycle.
• Your patients who are our members are randomly selectedforeachdatacollectioncycle.Yourofficemayreceivethisnotificationletterbutnothaveanypatients included for the HEDIS 2015 cycle. You will not need to take action unless contacted directly by UnitedHealthcare or a vendor working on our behalf.
• Ifyourofficeiscontacted,pleaserespondwithinfivebusiness days. A timely response helps ensure the data we report to state and federal regulators and accreditationorganization,isaccurateandreflectsthehigh quality care that you strive to provide.
• The collection vendors that may contact you on our behalf include Enterprise Consulting Solutions, Inc.,
RecordFlow, HealthPort and Altegra Health. They will arrange with you a convenient medical record collection time, or let you know if the records can be faxed, mailed or sent electronically. UnitedHealthcare staff may also contact you directly to ask for certain medical record information to be faxed or mailed.
• Vendorsaresubjecttoprivacy,confidentialityandthe Health Insurance Portability and Accountability Act (HIPAA) business associate requirements. The HIPAAPrivacyRuleallowsforexchangeofconfidentialpatient information to conduct Treatment, Payment, or Healthcare Operations and may occur without any writtenconsentorauthorizationbythepatient/memberbetween covered entities and UnitedHealthcare.
• If a patient chart included on the list we provide to you is not available at your practice location, or a patient is listed that has not ever received services from your practice, please alert the contact person or entity on the list immediately.
We appreciate the time and attention you and your officearetakingtofulfilltheseannualrequirements.Please contact us at 877-211-6545 or [email protected] with any questions.
*Under the Health Insurance Portability and Accountability Act (HIPAA), health care operations include disclosure of Protected Health Information (PHI) for accreditation (e.g., Healthcare EffectivenessDataandInformationSet(HEDIS)reporting)andcertificationactivities.Thesedisclosures may be made to a business associate, acting on behalf of the covered entity. The American Recovery and Reinvestment Act of 2009 (ARRA) also permits release of records. Our vendors have executed HIPAA-compliant business associate agreements to perform the medical records reviews.
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
UnitedHealthcare Medicare Advantage Coverage Summary Updates
Forcompletedetailsontheupdated/revisedpolicieslistedin the table on the following page refer to the Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com> Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.
UnitedHealthcare Medicare Solutions
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UnitedHealthcare Medicare Solutions
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Policy Title Approval Date Update Bulletin
TAKE NOTE
Availability of the Medicare Advantage Coverage Summary Update Bulletin
N/A Jan. 2015
UPDATED/REVISED
Abortion Nov. 18, 2014 Dec. 2014
Age Related Macular Degeneration (AMD) Therapy (Macugen ®, Lucentis ®, Avastin®, EYLEA®)
Oct. 21, 2014 Nov. 2014
Alcohol,Chemicaland/orSubstanceAbuse- DetoxificationandRehabilitation
Nov. 18, 2014 Dec. 2014
Blood, Blood Products and Related Procedures and Drugs Nov. 18, 2014 Dec. 2014
Breast Reconstruction Following Mastectomy Oct. 21, 2014 Nov. 2014
CardiacPacemakersandDefibrillators Oct. 21, 2014 Nov. 2014
Change in Membership Status while Hospitalized (Acute, LTC and SNF) or Receiving Home Health
Nov. 18, 2014 Dec. 2014
Chemotherapy, and Associated Drugs and Treatments Oct. 21, 2014 Nov. 2014
Cochleostomy with Neurovascular Transplant for Meniere's Disease Oct. 21, 2014 Nov. 2014
Court, Attorney or Agency Requested Services Nov. 18, 2014 Dec. 2014
Dental Services, Oral Surgery and Treatment of Temporomandibular Joint (TMJ)
Oct. 21, 2014 Nov. 2014
Diabetes Management, Equipment and Supplies Oct. 21, 2014 Nov. 2014
Diagnostic Pap Smear Nov. 18, 2014 Dec. 2014
Durable Medical Equipment (DME), Prosthetics, CorrectiveAppliances/Orthotics(Non-FootOrthotics) and Medical Supplies Grid
Oct. 21, 2014 Nov. 2014
DurableMedicalEquipment,Prosthetics,CorrectiveAppliances/Orthotics and Medical Supplies
Oct. 21, 2014 Nov. 2014
UnitedHealthcare Medicare Advantage Coverage Summary Updates
UnitedHealthcare Medicare Solutions
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Policy Title Approval Date Update Bulletin
Educational Programs Oct. 21, 2014 Nov. 2014
Emergent/UrgentServices,Post-StabilizationCare and Out-of-Area Services
Nov. 18, 2014 Dec. 2014
Extracorporeal Photopheresis Oct. 21, 2014 Nov. 2014
Impotence Treatment Oct. 21, 2014 Nov. 2014
Incontinence - Urinary and Fecal Incontinence, Diagnosis and Treatments
Oct. 21, 2014 Nov. 2014
Infertility Services Oct. 21, 2014 Nov. 2014
Infusion Pump Therapy Oct. 21, 2014 Nov. 2014
Medications/Drugs(Outpatient/PartB) Oct. 21, 2014 Nov. 2014
Nov. 18, 2014 Dec. 2014
Mobility Assistive Equipment (MAE) Oct. 21, 2014 Nov. 2014
Oxygen for Home Use Oct. 21, 2014 Nov. 2014
Pain Management and Pain Rehabilitation Oct. 21, 2014 Nov. 2014
Preventive Health Services and Procedures Oct. 21, 2014 Nov. 2014
Rehabilitation - Cardiac Rehabilitation Services (Outpatient) Oct. 21, 2014 Nov. 2014
Nov. 18, 2014 Dec. 2014
Renal Services and Procedures Oct. 21, 2014 Nov. 2014
Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services
Oct. 21, 2014 Nov. 2014
Shoes and Foot Orthotics Oct. 21, 2014 Nov. 2014
Skin Treatment, Services and Procedures Oct. 21, 2014 Nov. 2014
UnitedHealthcare Medicare Advantage Coverage Summary Updates
UnitedHealthcare Medicare Solutions
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UnitedHealthcare Medicare Advantage Coverage Summary Updates
Policy Title Approval Date Update Bulletin
Sleep Apnea - Diagnosis and Treatment Oct. 21, 2014 Nov. 2014
Nov. 18, 2014 Dec. 2014
Speech Generating Devices Oct. 21, 2014 Nov. 2014
Spine Procedures Oct. 21, 2014 Nov. 2014
Stimulators – Electrical and Spinal Cord Stimulators Oct. 21, 2014 Nov. 2014
Stimulators – Osteogenic Stimulators Oct. 21, 2014 Nov. 2014
Transcatheter Heart Valve Procedures Nov. 18, 2014 Dec. 2014
Uterine Services and Procedures Oct. 21, 2014 Nov. 2014
Varicose Veins Treatment Oct. 21, 2014 Nov. 2014
VentricularAssistDevice(VAD)andArtificialHeart Oct. 21, 2014 Nov. 2014
Vision Services, Therapy and Rehabilitation Oct. 21, 2014 Nov. 2014
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
UnitedHealthcare Commercial
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For complete details on the policy updates listed in the table on the following page, please refer to the monthly Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
UnitedHealthcare Commercial
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UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates All Jan. 1, 2015 Jan. 2015
Availability of the Medical Policy Update Bulletin All N/A Jan. 2015
NEW
Entyvio (Vedolizumab) Drug Policy Mar. 1, 2015 Dec. 2014 Jan. 2015
Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion
Utilization Review Guideline
Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015
Simponi Aria (Golimumab) Drug Policy Mar. 1, 2015 Dec. 2014 Jan. 2015
Vimizim (Elosulfase Alfa) Drug Policy Jan. 1, 2015 Oct. 2014Nov. 2014Dec. 2014
UPDATED/REVISED
Actemra (Tocilizumab) Drug Policy Dec. 1, 2014 Nov. 2014
Alemtuzumab Drug Policy Jan. 1, 2015 Dec. 2014
Autologous Chondrocyte Implantation in the Knee Medical Policy Dec. 1, 2014 Nov. 2014
Bariatric Surgery Medical Policy Dec. 1, 2014 Nov. 2014
Breast Reconstruction Post Mastectomy Coverage Determination Guideline
Dec. 1, 2014 Nov. 2014
BreastRepair/Reconstruction Not Following Mastectomy
Coverage Determination Guideline
Dec. 1, 2014 Nov. 2014
Cardiovascular Disease Risk Tests Medical Policy Dec. 1, 2014 Nov. 2014
Clotting Factors and Coagulant Blood Products Drug Policy Jan. 1, 2015 Dec. 2014
Computed Tomographic Colonography Medical Policy Jan. 1, 2015 Dec. 2014
UnitedHealthcare Commercial
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com1919 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies and Repairs/Replacements
Coverage Determination Guideline
Jan. 1, 2015 Dec. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Medical Policy Dec. 1, 2014 Nov. 2014
Fecal DNA Testing Medical Policy Dec. 1, 2014 Dec. 2014
Femoroacetabular Impingement Syndrome Medical Policy Jan. 1, 2015 Dec. 2014
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Medical Policy Jan. 1, 2015 Dec. 2014
Human Epidermal Growth Factor Receptor 2 (HER2) Targeting Drugs
Drug Policy Dec. 1, 2014 Nov. 2014
Immune Globulin (IVIG and SCIG) Drug Policy Jan. 1, 2015 Dec. 2014
Intensity-Modulated Radiation Therapy Medical Policy Jan. 1, 2015 Nov. 2014 Dec. 2014
Intensive Behavioral Therapy for Autism Spectrum Disorder
Medical Policy Dec. 1, 2014 Nov. 2014
Minimally Invasive Procedures for GastroesophagealRefluxDisease(GERD)
Medical Policy Dec. 1, 2014 Nov. 2014
Omnibus Codes Medical Policy Jan. 1, 2015 Dec. 2014
Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors
Drug Policy Dec. 1, 2014 Nov. 2014
Orencia (Abatacept) Drug Policy Dec. 1, 2014 Nov. 2014
Preventive Care Services Coverage Determination Guideline
Jan. 1, 2015 Dec. 2014
Remicade(Infliximab) Drug Policy Dec. 1, 2014 Nov. 2014
Sandostatin (Octreotide Acetate) Drug Policy Jan. 1, 2015 Dec. 2014
Speech Therapy Coverage Determination Guideline
Dec. 1, 2014 Nov. 2014
Stelara (Ustekinumab) Drug Policy Jan. 1, 2015 Dec. 2014
Vagus Nerve Stimulation Medical Policy Dec. 1, 2014 Nov. 2014
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization Review Guideline Updates
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
UnitedHealthcare Commercial
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2020 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
RadiologyandCardiologyNotification/PriorAuthorizationProtocols for the State of Rhode Island Effective Feb 1, 2015 – Training Opportunity
EffectiveFeb.1,2015providerspracticinginRhodeIslandmustprovidenotificationpriorto scheduling a planned service that is subject to UnitedHealthcare’s Outpatient Radiology Notification/PriorAuthorizationProtocolandCardiologyNotification/PriorAuthorizationProtocols.
These protocols include a prior authorization requirement that applies when a UnitedHealthcare Commercial or UnitedHealthcareCommunityPlanmember’sbenefitdocument requires health services to be medically necessary in order to be covered. As such, once notificationofaplannedserviceisreceived,CareCoreNational, LLC, a company with which UnitedHealthcare has contracted, will conduct a clinical coverage review if the member’sbenefitdocumentrequireshealthservicestobemedically necessary in order to be covered. • TheRadiologyNotification/PriorAuthorization
ProtocolandCardiologyNotification/PriorAuthorization Protocol for Commercial customers are located in UnitedHealthcare’s Physician, Health Care Professional, Facility and Ancillary Provider 2014 Administrative Guide for Commercial and Medicare Advantage Products (“Administrative Guide”). The Administrative Guide is available at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols & Guides > Administrative Guides. Additional information regarding these protocols is also available in the November 2014 Network Bulletin.
• The Cardiology Prior Authorization protocol for UnitedHealthcare Community Plan member is located on UnitedHealthcareOnline.com > Clinician Resources > Cardiology > UnitedHeatlhcare Community Plan Cardiology Prior Authorization Program. Additional information regarding this protocol is also available in the November 2014 Network Bulletin at UnitedHealthcareOnline.com > Network Bulletin.
Training OpportunitiesIf you still have questions after reviewing this information, please join us for a live question and answer telephone conferences:• Jan. 13, 2015
• Jan. 22, 2015
You can register to attend the conference at: UnitedHealthcareOnline.com > Clinician Resources > Radiology. UnitedHealthcareOnline.com > Clinician Resources > Cardiology
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2121 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
ImportantChangesinAdvanceNotificationand Prior Authorization Requirements
Effective for dates of service on or after Jan 1, 2015, advancenotificationorpriorauthorizationrequirementsfor certain services have been made for the following states: Florida, Hawaii, Iowa, Louisiana, Massachusetts, Mississippi, New Mexico, Rhode Island and Tennessee.
The most up-to-date list of procedures that will continue to require advancenotificationorpriorauthorization,aswellastheeffectivedate for each state for UnitedHealthcare Community Plan, can be found at UnitedHealthcareOnline.com > Tools & Resources > UnitedHealthcare Community Plan Resources.
The added codes are:Category: Home Health CareAdded Codes: Y1004, Y1004
Somemembershavebenefitplansthatprovideforpre-serviceclinical coverage reviews, while others do not. The process to requestadvancenotificationorpriorauthorizationisthesame,regardlessofthetypeofbenefitplan,andwillnotchange.
UnitedHealthcare Community Plan
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UnitedHealthcare Community Plan
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
ImportantChangesinAdvanceNotificationand Prior Authorization Requirements
If you are planning to perform a service on the standardized list, please notify us in advance. We will let you know if a clinical coverage review is required for that service and ask you to submit the necessary information to complete the review. Once a coverage determination is made, we will share that decision with you so you and your patient can make informed decisions before services are performed. We determine coverage consistent with the member’s benefitplan.
Please keep in mind that while receipt of an approved advancenotificationorpriorauthorizationforservicesconfirmscoverage,itdoesnotguaranteeorauthorizepayment. Payment of covered services is subject to the terms and conditions of your contract with UnitedHealthcareandthemember’shealthbenefit plan in effect at the time services are rendered, including but not limited to exclusions, limitations, conditions, patient eligibility, medical policies and claim processing requirements.
UnitedHealthcare Community Plan
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2323 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
For complete details on the policy updates listed in the table below, refer to the monthly Medical Policy Update Bulletin at UHCCommunityPlan.com > Provider Information > Medical Policies and Coverage Determination Guidelines for Community Plan.
Medical Policy & Coverage Determination Guideline Updates
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates All Jan. 1, 2015 Jan. 2015
Availability of the Community Plan Medical Policy Update Bulletin
All N/A Jan. 2015
UPDATED/REVISED
Autologous Chondrocyte Transplantation in the Knee Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Bariatric Surgery Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Breast Reconstruction Post Mastectomy Coverage Determination Guideline
Jan. 1, 2015 Nov. 2014Dec.2014
BreastRepair/Reconstruction Not Following Mastectomy
Coverage Determination Guideline
Jan. 1, 2015 Nov. 2014Dec.2014
Cardiovascular Disease Risk Tests Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Computed Tomographic Colonography Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015
Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies andRepairs/Replacements
Coverage Determination Guideline
Feb. 1, 2015 Dec. 2014Jan. 2015
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
UnitedHealthcare Community Plan
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2424 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Medical Policy & Coverage Determination Guideline Updates
Policy Title Policy Type Effective Date
Medical Policy Update Bulletin
Fecal DNA Testing Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015
Femoroacetabular Impingement Syndrome Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015
Intensity-Modulated Radiation Therapy Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Intensive Behavioral Therapy for Autism Spectrum Disorder
Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Minimally Invasive Procedures for Gastroesophageal RefluxDisease(GERD)
Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Omnibus Codes Medical Policy Feb. 1, 2015 Dec. 2014Jan. 2015
Vagus Nerve Stimulation Medical Policy Jan. 1, 2015 Nov. 2014Dec.2014
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
UnitedHealthcare Community Plan
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2525 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Changes to the Cardiology Prior Authorization Protocol for Rhode Island Medicaid Members Effective Feb. 1, 2015
Effective Feb. 1, 2015, select cardiology procedures will require prior authorization.
Providers must notify UnitedHealthcare prior to scheduling diagnostic catheterizations, electrophysiology implants, echocardiograms and stress echocardiograms for UnitedHealthcare Community Plan members). The cardiologyproceduresforwhichadvancednotification is required are:• Diagnostic catheterizations
• Electrophysiology implants
• Echocardiograms
• Stress echocardiograms
A complete listing of the current procedural terminology (CPT)codesforwhichnotificationisrequiredcanbefound at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Medicaid Cardiology Prior Authorization Program > Important Program Information > UnitedHealthcare Community Plan Cardiology Prior Authorization CPT Code Crosswalk.
More information regarding this protocol for UnitedHealthcare Community Plan members is available in the November 2014 Network Bulletin or at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > UnitedHealthcare Community Plan Cardiology Prior Authorization Program.
We will host live question and answer conference calls to further explain the new requirements on:• Jan. 13, 2015
• Jan. 22, 2015
To register, go to: UnitedHealthcareOnline.com > Clinician Resources > Radiology UnitedHealthcareOnline.com > Clinician Resources > Cardiology
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2626 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
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,includinglegislativemandates,enrolleebenefitcoveragedocuments, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols > Reimbursement Policies-Commercial. In the event ofaninconsistencyorconflictbetweentheinformationprovidedin the Network Bulletin and the posted policy, the provisions of the posted policy prevail.
UnitedHealthcare Commercial Reimbursement Policy
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UnitedHealthcare Commercial Reimbursement Policy
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2727 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
The Centers for Medicare and Medicaid Services (CMS) has created four new healthcare commonprocedurecodingsystem(HCPCS)modifierstoselectivelyidentifysubsetsofmodifier59 (distinct procedural services) for use, effective Jan. 1, 2015. They are:
• XE Separate Encounter: A service that is distinctbecause it occurred during a separate encounter.
• XP Separate Practitioner: A service that is distinctbecause it was performed by a different physician.
• XS Separate Structure: A service that isdistinct because it was performed on a separateorgan/structure.
• XU Unusual Non-Overlapping Service: A servicethat is distinct because it does not overlap usualcomponents of the main service.
Thesemodifiers,collectivelyreferredtoasX{EPSU}modifiers,definespecificsubsetsofmodifier59.Like CMS,UnitedHealthcarewillcontinuetorecognizemodifier59; however, current procedural terminology (CPT) instructionsstatethatmodifier59shouldnotbeusedwhenamoredescriptivemodifierisavailable.Inaddition,theX{EPSU}modifiersaremoreselectiveversionsofmodifier59soitwouldbeincorrecttoincludebothmodifiersonthesame line.
CMSwillcontinuetorecognizemodifier59butmayselectivelyrequireamorespecificX{EPSU}modifierforbilling certain codes at high risk for incorrect billing. For example, a particular national correct coding initiative (NCCI) procedure to procedure code pair edit may be identifiedaspayableonlywiththeXEseparateencountermodifierbutnotthe59orotherX{EPSU}modifiers.
UnitedHealthcarewillrecognizethesenewmodifiers,effective for dates of service on and after Jan. 1, 2015. PleasereferencethefollowingtabletofindoutwhenthenewmodifierswillbeconsideredinadministeringtheUnitedHealthcare’s reimbursement policies.
New“X”ModifiersandImpacttoUnitedHealthcare Commercial Reimbursement Policies
Policy
X{EPSU} Modifiers considered in lieu of Modifier 59
Effective for claims with dates of service Jan. 1, 2015 processed on or after these dates:
Anesthesia XE and XU Feb. 15, 2015
Bilateral XS Jan. 1, 2015
CCI Editing XE, XP, XS, and XU Jan. 1, 2015
Laboratory Services
XE, XP, XS, and XU Feb. 15, 2015
Maximum Frequency Per Day
XE, XS, and XU Jan. 1, 2015
Obstetrical XE, XS, and XU Feb. 15, 2015
Pediatric and Neonatal Critical & Intensive Care Services
XE, XS and XU New policy becomes effective March 1, 2015 DOS
Procedure toModifier
XE, XP, XS, and XU Feb. 15, 2015
Professional-Technical Component
XE, XP, XS, and XU Feb. 15, 2015
Radiology Multiple Imaging Reduction
XE Jan. 1, 2015
Rebundling XE, XP, XS, and XU Feb. 15, 2015
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2828 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Introducing a New Civilian Referral Request Form
To improve both the quality and clarity of provider requests, UnitedHealthcare Military & Veterans has enhanced our Civilian Referral Request Form used to submit requests for care.
The new form has been redesigned to be more precise and intuitive for providers when requesting care for specialty referrals, outpatient,inpatient,anddurablemedicalequipment(DME)/homehealth requests. The previous form will continue to be accepted until Feb. 1, 2015.
Changes include:• Added Date of Service to top of form to indicate desired
beginning date of service.
• AdditionofEpisodeofCareFieldtoallowspecificEOCselection (link to table below).
• AddedBenefitsNumberalongwithSponsorSSNandcheckboxes to indicate selection.
• Added option to use NPI and indicator for which number isprovided (NPI or TIN).
• Addeddefinitionof“Urgent”totopofformtolimitusetosituations where care is needed within 72 hours.
Effective Feb. 1, 2015 any referral requests submitted on the outdated form will be rejected, with a request to utilize the new form.
UnitedHealthcare Military & Veterans
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com2929 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Effective Feb. 25, 2015, UnitedHealthcare will apply additional WEDI Strategic National Implementation Process (SNIP) HIPAA edits to professional (837p) and institutional (837i) claims submitted electronically to most UnitedHealthcare andaffiliatepayer IDs.* These are new edits that were not applied with the edit enhancements released in 2014. For more information on current and previous edit releases, visit the Enhanced Claim Edits section of UnitedHealthcareOnline.com.
Because the new edits will be applied on a pre-adjudication basis, an increase in the number of claim rejections may occur. This will enable you to identify and correct rejected information prior to the claim’s acceptance into our adjudication system for processing. Thebenefitwillbefewerdeniedclaimsandlessinterruptiontorevenue streams.
Enhanced HIPAA Claim Edits Planned for February 2015
Doing Business Better
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Doing Business Better
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3030 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
The primary impact to you will come from edits that will validate code sets (such as diagnosis, procedure and modifiercodes)atapre-adjudicationlevel.Thenew edits and the complete list of enhanced edits have been distributed to clearinghouses and software vendors.
It’s important to check all of your claim submission reports regularly. Claims may be rejected by your clearinghouse or UnitedHealthcare; therefore, you may receive multiple reports per submission.
Rejections that may occur from the enhanced edits will appear at a clearinghouse level. Your Electronic Data Interchange (EDI) vendor or clearinghouse should be your firstpointofcontactforassistanceregardingtheseeditsorto resolve rejections. For assistance from UnitedHealthcare, please contact EDI Support:
* Excluded: Harvard Pilgrim (04271), Medica HealthCare Plans (78857), Preferred Care Partners (65088), the Alliance (88461) and TRICARE West (99726)
Enhanced HIPAA Claim Edits Planned for February 2015
UnitedHealthcare Commercial, UnitedHealthcare Medicare Solutions and UnitedHealthcare West
EDI issue reporting form or 800-842-1109
UnitedHealthcare Community Plan [email protected] or 800-210-8315
UnitedHealthcare Oxford [email protected] or 800-599-4334
UnitedHealthcare Medicare Solutions Coinsurance Calculation Reminder for Providers
For all AARP MedicareComplete products, coinsurance should be calculated as follows:
1. Forservicesreimbursedviaaservice-specificcontracted rate, or on a fee-for-service basis:coinsurance is based on the contracted rate orbilled amount, whichever is less or as agreedupon in the provider contract
2. For services reimbursed under a downstreamcapitation agreement, between your organizationand a provider of the service, and where paymentisnotissuedforeachspecificservicerendered:Coinsurance is based on the MedicareAllowable Rate for the locality in which theservice is rendered.
This method of coinsurance calculation is consistent withthedefinitionof“coinsurance”foundinmembermaterials, i.e., the Evidence of Coverage, and the methodology intended for all UnitedHealthcare Medicare Advantage products nationwide. Additionally, as the coinsurance calculation is a critical portionoftheExplanationofBenefits(EOB)sentto the member, the correct set up and consistent calculation of coinsurance may reduce member appeals and complaints to Medicare.
To learn more, please visit uhcwest.com > Provider > Library > [State] > Publications > Provider Communication Highlights or contact your local Network Account Manager or Provider Advocate.
Doing Business Better
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Coverage Determinations and Utilization Management Decisions
At UnitedHealthcare, coverage decisions on health care services are based on the member’s benefitdocumentsandapplicablestateandfederal requirements. For Commercial members, this includes the contract the member’s employer plan sponsor has with UnitedHealthcare. For Medicare Advantage members, this includes but is not limited to, national coverage determinations, local coverage determinations and general Medicare coverage guidelines.
The coverage decisions are made based on:• For Commercial members, the appropriateness of
care and services and the existence of coverage asdefinedwithinthecontractourCommercialmember’semployer has with UnitedHealthcare or;
• ForMedicareAdvantagemembers,thedefinitionof“reasonable and necessary” within Medicare coverage regulations and guidelines.
The staff of UnitedHealthcare, its delegates, and the physicians making these coverage decisions are not compensated or otherwise rewarded for issuing non-coverage decisions. UnitedHealthcare and its delegates do not offer incentives to physicians or utilization management decision makers to encourage underutilization of care or services or to encourage barriers to care and service. Hiring, promoting or terminating practitioners or other individuals is not based on the likelihood or perceived likelihood that the individual will support or tend to support thedenialofbenefits.
UnitedHealthcare Negotiates National Contract with Medway Air Ambulance, Inc. for Fixed-Wing Air Ambulance Services
As part of UnitedHealthcare’s strategy to improve the air ambulance network available to our members and facilities, UnitedHealthcare has contracted Medway Air Ambulance for nationwide domestic air ambulance trips in order to reduce medical spend while ensuring quality and consistent service to our members. Due to the structure of many benefit plans, members who receive services provided by a non-network air ambulance provider may incur increased financial liability and be exposed to higher out-of-pocket expenses.
Medway Air Ambulance can be reached at 800-233-0655. Please refer patients to in-network air ambulance providers, such as Medway, as outlined in your network participation agreement.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3232 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
For complete details on the policy updates listed in the table on the following page, please refer to the monthly Policy Update Bulletin at UHCRiverValley.com > Providers > Coverage Policy Library > Policy Update Bulletin.
UnitedHealthcare AffiliatesUnitedHealthcare of the River Valley Preauthorization List and Policy Updates
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UnitedHealthcare Affiliates
TABLE OF CONTENTS
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or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
UnitedHealthcare of the River Valley Preauthorization List and Policy Updates
These updates apply to UnitedHealthcare of the River Valley commercial and hawk-i plan membership only.
Policy Title Effective Date Coverage Policy Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates Jan. 1, 2015 Jan. 2015
Availability of the River Valley Policy Update Bulletin N/A Jan. 2015
NewPreauthorizationRequirementsforRadiology/AdvancedOutpatient Imaging Procedures
Feb. 16, 2015 Nov. 2014Dec. 2014Jan. 2015
Reimbursement Policies that Apply to Commercial Claims that are Subject to the River Valley Entities Supplement
TBD (Delayed) Nov. 2014
NEW
Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion
Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015
Radiology/AdvancedOutpatientImagingProcedures Feb. 16, 2015 Nov. 2014Dec. 2014Jan. 2015
UPDATED/REVISED
Actemra® (Tocilizumab) Jan. 1, 2015 Dec. 2014
Autologous Chondrocyte Transplantation in the Knee Dec. 1, 2014 Nov. 2014
Bariatric Surgery Dec. 1, 2014 Nov. 2014
Breast Reconstruction Post-Mastectomy Jan. 1, 2015 Dec. 2014
BreastRepair/Reconstruction(NotFollowingMastectomy) Jan. 1, 2015 Dec. 2014
Cardiology - Diagnostic Catheterization, Electrophysiology (EP) Implants, Echocardiogram and Stress Echocardiogram
Jan. 1, 2015 Dec. 2014
Cardiovascular Disease Risk Tests Dec. 1, 2014 Nov. 2014
Computed Tomographic Colonography Jan. 1, 2015 Dec. 2014
UnitedHealthcare Affiliates
TABLE OF CONTENTS
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3434 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
UnitedHealthcare of the River Valley Prior Authorization List and Policy Updates
Policy Title Effective Date Coverage Policy Update Bulletin
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Dec. 1, 2014 Nov. 2014
Fecal DNA Testing Dec. 1, 2014 Dec. 2014
Femoroacetabular Impingement Syndrome Jan. 1, 2015 Dec. 2014
Hearing Aids and other Devices Including Wearable, Bone Anchored and Semi-Implantable
Jan. 1, 2015 Dec. 2014
Hereditary Angioedema (HAE), Treatment and Prophylaxis Dec. 1, 2014 Nov. 2014
Human Epidermal Growth Factor Receptor 2 (HER2) Targeting Drugs
Jan. 1, 2015 Dec. 2014
Intensity-Modulated Radiation Therapy Jan. 1, 2015 Nov. 2014Dec. 2014
Intensive Behavioral Therapy for the Treatment of Autism Spectrum Disorder
Dec. 1, 2014 Nov. 2014
Minimally Invasive Procedures for Gastroesophageal RefluxDisease(GERD)
Dec. 1, 2014 Nov. 2014
Omnibus Codes Jan. 1, 2015 Dec. 2014
Oncology Medication Clinical Coverage Policy Dec. 1, 2014 Nov. 2014
Ophthalmologic Policy - Vascular Endothelial Growth Factor (VEGF) Inhibitors
Jan. 1, 2015 Dec. 2014
Orencia® (Abatacept) Jan. 1, 2015 Dec. 2014
Pectus Deformity Repair Dec. 1, 2014 Nov. 2014
Preventive Care Services Jan. 1, 2015 Dec. 2014
Remicade®(Infliximab) Jan. 1, 2015 Dec. 2014
Routine Foot Care Jan. 1, 2015 Dec. 2014
Vagus Nerve Stimulation Dec. 1, 2014 Nov. 2014
Note: The inclusion of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure. In the event
of an inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
UnitedHealthcare Affiliates
TABLE OF CONTENTS
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3535 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Policy Title Applicable State(s) Effective Date
Update Bulletin
TAKE NOTE
AvailabilityoftheSignatureValue™BenefitInterpretation Policy Update Bulletin
All(California, Oklahoma, Oregon, Texas, & Washington)
Jan. 2015
NEW
Transgender:GenderIdentityDisorder/GenderDysphoria Treatment
Oregon Jan. 1, 2015 Dec. 2014
UPDATED/REVISED
Biofeedback All Jan. 1, 2015 Dec. 2014
Change in Membership Status and Continuity of Care All Jan. 1, 2015 Dec. 2014
Chemotherapy California, Oklahoma, & Texas Jan. 1, 2015 Dec. 2014
Clinical Trials: Routine Costs in Clinical Trials All Jan. 1, 2015 Dec. 2014
Dental Care and Oral Surgery All Jan. 1, 2015 Dec. 2014
Developmental Delay and Learning Disabilities All Nov. 1, 2014 Nov. 2014
Durable Medical Equipment (DME), Prosthetics, CorrectiveAppliances/Orthotics(NonFootOrthotics)and Medical Supplies Grid
All Dec. 1, 2014 Nov. 2014
Experimentaland/orInvestigationalProcedures,Items,and Treatments
All Dec. 1, 2014 Nov. 2014
Hearing: Hearing Screening, Hearing Examinations and Hearing Aids
All Jan. 1, 2015 Dec. 2014
SignatureValue™BenefitInterpretationPolicyUpdates
For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
UnitedHealthcare Affiliates
TABLE OF CONTENTS
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3636 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
SignatureValue™BenefitInterpretation Policy Updates
Policy Title Applicable State(s) Effective Date
Update Bulletin
Hospice Care and Services All Jan. 1, 2015 Dec. 2014
Immunizations/Vaccinations All Dec. 1, 2014 Nov. 2014
Inpatient Hospital Services All Dec. 1, 2014 Nov. 2014
Maternity and Newborn Care All Jan. 1, 2015 Dec. 2014
Outpatient Hospital Services All Dec. 1, 2014 Nov. 2014
Radiology: Diagnostic and Therapeutic Radiology Services
All Jan. 1, 2015 Dec. 2014
Sexual Dysfunction: Erectile Dysfunction (Impotence) All Jan. 1, 2015 Dec. 2014
Surgery: Cosmetic, Reconstructive or Plastic Surgery All Dec. 1, 2014 Nov. 2014
Vision: Vision Care and Services All Nov. 1, 2014 Oct. 2014Nov. 2014
RETIRED
Hospital Observation: Observation Care (Outpatient Hospital)
All Dec. 1, 2014 Dec. 2014
Ostomy: Ostomy Supplies All Dec. 1, 2014 Nov. 2014
Ostomy Supplies Grid All Dec. 1, 2014 Dec. 2014
Surgery: Orthognathic Surgery All Nov. 1, 2014 Nov. 2014
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
UnitedHealthcare Affiliates
TABLE OF CONTENTS
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3737 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Policy Title Effective Date Update Bulletin
TAKE NOTE
Annual CPT® and HCPCS Code Updates Jan. 1, 2015 Jan. 2015
Availability of the SignatureValue™ Medical Management Guidelines Update Bulletin
N/A Jan. 2015
NEW
Immune Globulin Site of Care Review Guidelines for Medical Necessity Of Hospital Outpatient Facility Infusion
Feb. 1, 2015 Nov. 2014Dec. 2014Jan. 2015
UPDATED/REVISED
Autologous Chondrocyte Transplantation in the Knee Dec. 1, 2014 Nov. 2014
Bariatric Surgery Dec. 1, 2014 Nov. 2014
Blepharoplasty, Blepharoptosis, and Brow Ptosis Repair Dec. 1, 2014 Nov. 2014
Breast Reconstruction Post Mastectomy Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Breast Reduction Surgery Dec. 1, 2014 Nov. 2014
BreastRepair/ReconstructionNotFollowingMastectomy Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Cardiovascular Disease Risk Tests Dec. 1, 2014 Nov. 2014
Computed Tomographic Colonography Jan. 1, 2015 Dec. 2014
Cosmetic and Reconstructive Procedures Dec. 1, 2014 Nov. 2014
SignatureValue™ Medical Management Guideline Updates
For complete details on the policy updates listed in the following table, please refer to the monthly SignatureValue™ Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3838 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
SignatureValue™ Medical Management Guideline Updates
Policy Title Effective Date Update Bulletin
Durable Medical Equipment and Related Supplies, Prosthetics and Orthotic Policy
Jan. 1, 2015 Dec. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Dec. 1, 2014 Nov. 2014
Fecal DNA Testing Dec. 1, 2014 Dec. 2014
Femoroacetabular Impingement Syndrome Jan. 1, 2015 Dec. 2014
Gynecomastia Treatment Dec. 1, 2014 Nov. 2014
Hearing Aids and Devices Including Wearable, Bone-Anchored and Semi-Implantable
Jan. 1, 2015 Dec. 2014
Home Health Care Nov. 1, 2014 Nov. 2014
Intensity-Modulated Radiation Therapy Jan. 1, 2015 Nov. 2014Dec. 2014
Intensive Behavioral Therapy for Autism Spectrum Disorder
Dec. 1, 2014 Nov. 2014
Minimally Invasive Procedures for Gastroesophageal RefluxDisease(GERD)
Dec. 1, 2014 Nov. 2014
Obstructive Sleep Apnea Treatment Dec. 1, 2014 Nov. 2014
Omnibus Codes Jan. 1, 2015 Dec. 2014
Orthognathic (Jaw) Surgery Dec. 1, 2014 Nov. 2014
Panniculectomy and Body Contouring Procedures Dec. 1, 2014 Nov. 2014
Pectus Deformity Repair Dec. 1, 2014 Nov. 2014
Preventive Care Services Jan. 1, 2015 Dec. 2014
Rhinoplasty and Repair of Vestibular Stenosis Dec. 1, 2014 Nov. 2014
Surgical and Ablative Procedures for Venous InsufficiencyandVaricoseVeins
Dec. 1, 2014 Nov. 2014
Vagus Nerve Stimulation Dec. 1, 2014 Nov. 2014Dec. 2014
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com3939 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Oxford® Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Annual CPT® and HCPCS Code Updates All Jan. 1, 2015 Jan. 2015
Availability of the Oxford® Policy Update Bulletin All N/A Jan. 2015
SpecificHCPCSModifiersforDistinct Procedural Services
Reimbursement Policy
Jan. 1, 2015 Dec. 2014
NEW
Accreditation Requirements for Radiologists and Radiology Centers
Administrative Policy Dec. 1, 2014 Nov. 2014
Immune Globulin Site of Care Review Guidelines for Medical Necessity of Hospital Outpatient Facility Infusion
Clinical Policy Feb. 1, 2015 Dec. 2014
UPDATED/REVISED
Abortions (Therapeutic and Elective) Clinical Policy Jan. 1, 2015 Dec. 2014
Ambulance Policy Reimbursement Policy
Dec. 1, 2014 Nov. 2014
AssignmentofBenefitstoNon-NetworkProviders Administrative Policy Dec. 1, 2014 Nov. 2014
Autism Clinical Policy Dec. 1, 2014 Nov. 2014
Autologous Chondrocyte Transplantation in the Knee
Clinical Policy Jan. 1, 2015 Dec. 2014
Bariatric Surgery Clinical Policy Jan. 1, 2015 Dec. 2014
Breast Reconstruction Post Mastectomy Clinical Policy Jan. 1, 2015 Dec. 2014
BreastRepair/Reconstruction (Not Following a Mastectomy)
Clinical Policy Jan. 1, 2015 Dec. 2014
Cardiovascular Disease Risk Tests Clinical Policy Jan. 1, 2015 Dec. 2014
TAKE NOTE
For complete details on thenewand/orrevisedpolicies listed in the following table, refer to the monthly Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4040 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Claims Recovery Administrative Policy Jan. 1, 2015 Dec. 2014
Clinical Review Policy Administrative Policy Jan. 1, 2015 Dec. 2014
Clotting Factors and Coagulant Blood Products Clinical Policy Jan. 1, 2015 Dec. 2014
Core Decompression for Avascular Necrosis Clinical Policy Dec. 1, 2014 Nov. 2014
Credentialing Guidelines: Participation in the Radiology Network
Administrative Policy Dec. 1, 2014 Nov. 2014
Diabetes Supply Coverage Administrative Policy Dec. 1, 2014 Dec. 2014
Diabetes Supply Coverage for New Jersey Small Group and Individual Plans
Administrative Policy Dec. 1, 2014 Dec. 2014
Diabetic Insulins Clinical Policy Jan. 1, 2015 Dec. 2014
Dialysis Services Administrative Policy Dec. 1, 2014 Dec. 2014
Drug Coverage Criteria - New and Therapeutic Equivalent Medications
Clinical Policy Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Drug Coverage Guidelines Clinical Policy Oct. 15, 2014 Oct. 2014 Addendum Nov. 2014
Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Durable Medical Equipment, Orthotics and Prosthetics Multiple Frequency
Reimbursement Policy
Dec. 1, 2014 Nov. 2014
Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation
Clinical Policy Jan. 1, 2015 Dec. 2014
Emergency Room Visits Administrative Policy Dec. 1, 2014 Dec. 2014
Experimental/InvestigationalTreatment Administrative Policy Dec. 1, 2014 Dec. 2014
Experimental/InvestigationalTreatmentforNJPlans Administrative Policy Dec. 1, 2014 Dec. 2014
ExtendedBenefitsforTotalDisability Administrative Policy Jan. 1, 2015 Dec. 2014
Fecal DNA Testing Clinical Policy Dec. 1, 2014 Dec. 2014
Formula & Specialized Food Administrative Policy Dec. 1, 2014 Dec. 2014
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4141 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
From - To Date Policy Reimbursement Policy
Dec. 1, 2014 Nov. 2014
GeneticTestingforHereditaryBreastand/orOvarian Cancer Syndrome (HBOC)
Clinical Policy Dec. 1, 2014 Nov. 2014
Global Days Policy Reimbursement Policy
Dec. 1, 2014 Nov. 2014
Hospice Care Administrative Dec. 1, 2014 Dec. 2014
Human Menopausal Gonadotropins (hMG) Used in the Treatment of Infertility
Clinical Policy Jan. 1, 2015 Dec. 2014
In-OfficeLaboratoryTestingandProceduresList Clinical Policy Dec. 1, 2014 Nov. 2014
Lyme Disease Clinical Policy Dec. 1, 2014 Nov. 2014
Maximum Frequency Per Day Policy Reimbursement Policy
Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Medical Supplies Administrative Policy Dec. 1, 2014 Dec. 2014
Members Outside of the United States Administrative Policy Jan. 1, 2015 Dec. 2014
Minimally Invasive Procedures for Gastroesophageal RefluxDisease(GERD)
Clinical Policy Jan. 1, 2015 Dec. 2014
Moderate Sedation Policy Reimbursement Policy
Jan. 1, 2015 Dec. 2014
Neurophysiologic Testing Clinical Policy Dec. 1, 2014 Nov. 2014
Nonphysician Health Care Professionals Billing Evaluation and Management Codes Policy
Reimbursement Policy
Dec. 1, 2014 Nov. 2014
Obstetrical Policy Reimbursement Policy
Dec. 1, 2014 Nov. 2014
Obstructive Sleep Apnea Treatment Clinical Policy Dec. 1, 2014 Nov. 2014
Omnibus Codes Clinical Policy Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Oral Anti-Diabetic Agents (Janumet, Januvia, Janumet XR, Invokana, Farxiga)
Clinical Policy Jan. 1, 2015 Dec. 2014
Orencia (Abatacept) - Intravenous Infusion Clinical Policy Jan. 1, 2015 Dec. 2014
Osteochondral Grafting of Knee Clinical Policy Dec. 1, 2014 Nov. 2014
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4242 For more information call 877.842.3210,
or visit UnitedHealthcareOnline.comNetwork Bulletin: January 2015
Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Oxford's Outpatient Imaging Self-Referral Policy Clinical Policy Dec. 1, 2014 Nov. 2014
Jan. 1, 2015 Dec. 2014
Panniculectomy and Body Contouring Procedures Clinical Policy Dec. 1, 2014 Nov. 2014
Pectus Deformity Repair Clinical Policy Dec. 1, 2014 Nov. 2014
Preexisting Condition Administrative Policy Jan. 1, 2015 Dec. 2014
Prescription Drug Quantity Duration (QD) and Quantity Level Limitations (QLL)
Clinical Policy Jan. 1, 2015 Dec. 2014
Preventive Care Services Clinical Policy Jan. 1, 2015 Dec. 2014
Prosthetics Administrative Policy Dec. 1, 2014 Dec. 2014
Proton Pump Inhibitors Clinical Policy Jan. 1, 2015 Dec. 2014
Radiation Therapy Procedures for CareCore National Arrangement
Clinical Policy Jan. 1, 2015 Dec. 2014
Radiation Therapy Procedures RequiringPrecertification
Clinical Policy Jan. 1, 2015 Dec. 2014
Radiopharmaceuticals and Contrast Media Clinical Policy Dec. 1, 2014 Nov. 2014
Refractive Services Administrative Policy Dec. 1, 2014 Dec. 2014
Remicade(Infliximab) Clinical Policy Jan. 1, 2015 Dec. 2014
Supply Policy Reimbursement Policy
Jan. 1, 2015 Dec. 2014
Transcatheter Heart Valve Procedures Clinical Policy Dec. 1, 2014 Nov. 2014
Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting
Clinical Policy Dec. 1, 2014 Nov. 2014
Transitional Care Administrative Policy Jan. 1, 2015 Dec. 2014
Treatment of Infertility for New Jersey Large Groups Clinical Policy Dec. 1, 2014 Nov. 2014
Vagus Nerve Stimulation Clinical Policy Jan. 1, 2015 Dec. 2014
Virtual Upper Gastrointestinal Endoscopy Clinical Policy Dec. 1, 2014 Nov. 2014
Vision Services Clinical Policy Jan. 1, 2015 Dec. 2014
Visual Information Processing Evaluation and Orthoptic and Vision Therapy
Clinical Policy Dec. 1, 2014 Nov. 2014
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Network Bulletin: November 2013 - Volume 58 For more information call 877.842.3210, or visit UnitedHealthcareOnline.com4343 Insurance coverage provided by UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of
Arizona, Inc., UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by UnitedHealthcare Services, Inc. or its affiliates.
Network Bulletin: January 2015Doc#: PCA15345_20141218
Oxford Medical and Administrative Policy Updates
Policy Title Policy Type Effective Date
Policy Update Bulletin
UPDATED/REVISED
Warming Therapy and Ultrasound Therapy for Wounds
Clinical Policy Dec. 1, 2014 Nov. 2014
RETIRED
Biofeedback Clinical Policy Jan. 1, 2015 Jan. 2015
Oxygen Therapy and Equipment Clinical Policy Jan. 1, 2015 Jan. 2015
SmokingCessationforEssentialHealthBenefitGroups (Chantix, Nicotrol NS, Nicotrol Inhaler)
Clinical Policy Jan. 1, 2015 Dec. 2014
Note: The inclusion of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency between the information in this Network Bulletin and the posted policy, the posted policy will prevail.
Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford
insurance products are underwritten by Oxford Health Insurance, Inc.