Quick Summary: Complete Network Bulletin Available Here
FRONT AND CENTER (P 3)
UnitedHealthcare Special Needs Plan Model of Care Training (P 3)
- Please complete this year’s training by Dec. 16, 2016.
- To access the training schedule and register, please visit UnitedHealthcareOnline.com > Tools & Resources > Training & Education. Scroll to the section for Medicare & Medicaid Topics and click the link for 2016 Special Needs Plan Model of Care Training. You will need to register to start the pre-recorded session.
- If you have questions, please call 888-878-5499 or email UnitedHealthcare at firstname.lastname@example.org.
UnitedHealthcare Adds RadSite and The Joint Commission as Imaging Accreditation Organizations – Eff July 1, 2016 (P 4)
- We recognize the RadSite and TJC quality standards, and are enlisting their expertise in facilitating accreditation of imaging providers.
- UnitedHealthcare currently recognizes the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC) standards, and will continue to enlist their expertise in facilitating accreditation.
- UnitedHealthcare requires accreditation for advanced imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), nuclear medicine/cardiology and echocardiography procedures.
- UnitedHealthcare does not require accreditation as a condition of eligibility for reimbursement and will not administratively deny claims for advanced imaging studies for lack of accreditation.
- Refer to the July 2016 Network Bulletin for links and phone numbers to the UHC’s enlisted imaging accreditation organizations.
Outreach Efforts to Begin July 1 to Support Care Providers with Continued Adoption of Clinical Data Submission Protocol (P 5)
- As a result of the progress made to date, we will continue implementation of the Protocol to include our Medicaid and Commercial benefit plans as well as to be inclusive of all laboratory tests with outreach efforts to care providers to begin July 1.
- If you have not started transmitting clinical information to us, we can help you find a solution that works with your current systems and processes and offer a variety of solutions that can work to meet your specific needs.
- Refer to the July 2016 Network Bulletin to see to find more information about the Clinical Data Submission Protocol.
Changes in Advance Notification and Prior Authorization (P 6)
- Effective July 1, 2016, Medicare Solutions (including UnitedHealthcare Community Plan Medicare Advantage) will no longer require prior authorization for several services in the Home Health Services category. Please refer to the July 1, 2016 Advanced Notification & Prior Authorization Requirements at UnitedHealthcareOnline.com and UHCCommunityPlan.com.
Chemotherapy Prior Authorizations for Bendamustine Hydrochloride (P 6)
- For chemotherapy prior authorization requests made after April 7, 2016, for bendamustine HCL, you will now receive an approval, as appropriate, for both Treanda (J9033) and Bendeka.
- If a member has a current authorization that was approved prior to April 7, 2016 for Treanda and the member will now receive Bendeka, a new prior authorization request is necessary if you will be billing with a miscellaneous J code.
National Drug Codes Requirement to be Enforced for UnitedHealthcare Commercial & UnitedHealthcare Medicare Advantage Professional Claims, Effective Jan. 1, 2017 (P 7)
- Effective for claims with a date of service on or after Jan. 1, 2017, we will begin enforcing the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide for Commercial and Medicare Advantage Products national drug code (NDC) requirement.
- As a result, UnitedHealthcare Commercial and Medicare Advantage members’ professional claims submitted for reimbursement for drug-related codes must include the NDC number, quantity and the unit of measure.
- This requirement applies to paper claim form CMS-1500 and Electronic Data Interface (EDI) transaction 837P when billed for drug-related HCPCS codes and drug-related CPT codes.
- The NDC, quantity and the unit of measure will be enforced in addition to the corresponding healthcare common procedure coding system (HCPCS) and current procedure terminology (CPT) codes and the units administered for each code.
- Please note, hospital facility outpatient claims will not be subject to enforcement at this time.
- For additional information on how to submit an NDC, including frequently asked questions, please go to UnitedHealthcareOnline.com > Claims & Payments > Claim Submission > NDC Claim Submission > National Drug Code Requirement Frequently Asked Questions.
- For general contact information, please go to UnitedHealthcareOnline.com > Contact Us. If you have questions regarding how to submit an NDC through our EDI transactions, including but not limited to electronic claims (837), payer level rejections, electronic payments and statements (835), issues with eligibility (270/271) or claim status (276/277), please call 800-842-1109 or complete the EDI Transaction Support Form.
Dental Clinical Policy & Coverage Guideline Updates (P 8)
- For complete details on the policy updates listed in the following table, please refer to the May 2016 UnitedHealthcare Dental Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines > Update Bulletin
UNITEDHEALTHCARE COMMERCIAL (P 9)
UnitedHealthcare Exchange Update (P 9)
- Our decision to leave many individual markets in 2017 does not affect members in other products, including our group commercial, Medicare and Medicaid members.
- Our decisions will not affect members enrolled in individual plans in 2016.
- If you have questions or concerns regarding a member’s coverage status, please call Provider Services at 877-842-3210 to get up-to-date information prior to providing care. If one of your patients who is our member has questions, please ask them to call the number included in the letter they received on their options for 2017.
Participating Provider Laboratory & Pathology Protocol (P 10)
- UnitedHealthcare requires physicians and other qualified health care professionals to inform patients who are our members when referring them to or including a non-network provider in that patient’s health plan.
- You can access a copy of the protocol and consent form at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols.
- Use of network laboratories and pathologists is always required, except: (a) as otherwise authorized by UnitedHealthcare, (b) in an emergency situation, or (c) if a UnitedHealthcare member has made an informed decision to use a non-network laboratory or pathologist and you have followed the process outlined in the July 2016 Network Bulletin.
- For a list of network laboratories and pathologists: Go to UnitedHealthcareOnline.com and select Physician Directory at the top of the home page > Select General Physician Directory, and then select a plan. > Select Laboratory Facility or Laboratory – Nationally Contracted and enter your patient’s location.
- If you do not have an account with a UnitedHealthcare network laboratory, please set one up by Sept. 1, 2016. If you have questions, please call Provider Services at 877-842-3210.
Prescription Drug List and Pharmacy Benefit Updates (P 11)
- The July 1, 2016 prescription drug list and pharmacy benefit updates for UnitedHealthcare Commercial plans are available at UnitedHealthcareOnline.com > Tools & Resources > Pharmacy Resources > UnitedHealthcare Prescription Drug List.
UnitedHealth Premium® Physician Designation Program Assessment Results Coming in the Fall (P 12)
- This fall, we will mail the Premium designation letters to eligible physicians.
- Premium designations will be posted in our online directories, such as myuhc.com in early 2017.
- Physicians will have time to review their assessment reports prior to their designation displaying in our online directories and they will be able to request a reconsideration, if applicable.
- To take a training course and find more about the UnitedHealth Premium designation program, please go to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium > Premium Methodology > UnitedHealth Premium Designation Program – Training Course.
- If you have questions, please go to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium > Contact Premium Program. You may also call the Health Care Measurement Resource Center at 866-270-5588.
Reminder: UnitedHealth Premium Reconsideration Submission Deadline is July 15, 2016 (P 12)
- For complete details on the policy updates listed in the following table, please refer to the March 2016 UnitedHealthcare Dental Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Dental Clinical Policies & Coverage Guidelines > Update Bulletin. All of these policy updates are effective April 1, 2016.
UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates (P 13)
- For complete details on the policy updates listed in the following table, please refer to the May 2016 Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.
UNITEDHEALTHCARE COMMERCIAL REIMBURSEMENT POLICIES (P 15)
- Once implemented, the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies and Protocols > Reimbursement Policies-Commercial.
After Hours and Weekend Care Policy – Reimbursement Policy Change (P 16)
- Effective for Sept. 1, 2016 dates of service and after, UnitedHealthcare’s After Hours and Weekend Care Policy will be changed to allow reimbursement only for primary care participating providers for CPT code 99050.
- The revised After Hours and Weekend Care Policy reflecting this change will be published on Sept. 1, 2016. The revised policy will be accessible in September 2016 at UnitedHealthcareOnline.com under Tools & Resources > Policies, Protocols and Guides.
New Policy – Evaluation and Management Reimbursement Policy (P 16)
- The policy will provide additional guidance in determining the appropriate E&M codes for services in the range 99201 – 99350
- The policy will be published on Sept. 1, 2016, and can be accessed on UnitedHealthcareOnline.com under Tools & Resources > Policies, Protocols and Guides.
Revisions to the T Status Code and Laboratory Services Reimbursement Policies – Effective Q3 (P 17)
- UnitedHealthcare will only deny separate reimbursement of a CPT or HCPCS code assigned a status of T when also reported with a CPT or HCPCS code assigned a status of A, R or T by the same physician or other health care professional for the same patient and the same date of service.
- When two codes assigned a T status are reported without any other payable service, the T status code with the highest Relative Value Unit will be reimbursed.
- The two revised policies:
T Status Codes Policy
Laboratory Services Policy
- For a comprehensive list of services assigned a status of A, R, or T, please visit cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU16B.
UNITEDHEALTHCARE COMMUNITY PLAN (P 18)
UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates (P 19)
- For complete details on the policy updates listed in the following table, please refer to the May 2016 Medical Policy Update Bulletin at UHCCommunityPlan.com > For Health Care Professionals > Select Your State > Provider Information > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines.
- Claims Processing Change for Eight Professional Reimbursement Policies – Eff May 21, 2016 (P 20)
- UnitedHealthcare Community Plan will no longer correct recognized provider miscoding. Instead, we will issue denials in certain instances.
- Unless otherwise noted as follows, these reimbursement policies apply to services reported using the CMS-1500 or its electronic equivalent, or its successor form.
- The policies are available at UHCCommunityPlan.com > For Health Care Professionals > Select Your State > Reimbursement Policies.
UNITEDHEALTHCARE MEDICARE SOLUTIONS (P 23)
2016 Preferred Care Partners and Medica HealthCare Provider Manuals Available June 1, 2016 (P 23)
- The updated Preferred Care Partners Provider Manual will be available June 1, 2016 online at MyPreferredProvider.com > Provider Resources > Provider Manual.
- The updated Medica HealthCare Provider Manual will be available June 1, 2016 online at MedicaPlans.com > Physicians and Providers > Provider Manual.
- Except as otherwise noted, these 2016 provider manuals are effective on Sept. 1, 2016 for current network care providers and effective immediately for care providers who joined our network on or after June 1, 2016.
- Please see the Manuals at MyPreferredProvider.com and MedicaPlans.com.
Referral Responsibilities of PCPs and Specialists (P 25)
- UnitedHealthcare requires primary care providers (PCPs) to submit referrals online when our Medicare Advantage members require care from a specialist. We also require specialists to validate referrals before seeing patients.
New Reimbursement Policy Addresses Maximum Allowable Units per Day for CPT and HCPCS Codes (P 26)
- UnitedHealthcare Medicare Advantage will implement the new Maximum Frequency per Day Policy to address maximum allowable units per day for CPT and Healthcare Common Procedure Coding System (HCPCS) codes where the Centers for Medicare and Medicaid Services (CMS) has not published a National Correct Coding Initiative (NCCI) Medically Unlikely Edit (MUE) or units value. For codes with a CMS MUE, the new Maximum Frequency per Day Policy will not apply.
- Effective with dates of service on and after Sept. 1, 2016, UnitedHealthcare will reimburse units for services not addressed by a CMS MUE value according to the Maximum Frequency per Day policy.
New Reimbursement Policy Addresses Time Span Codes (P 26)
- UnitedHealthcare Medicare Advantage will implement a new policy that addresses CPT® and Healthcare Common Procedure Coding System (HCPCS) codes that, by their code description, should only be submitted weekly, monthly, annually or for a time period other than daily.
- Effective with dates of service on and after Sept. 1, 2016, UnitedHealthcare Medicare Solutions will reimburse time span codes reported by physicians and/or other health care professionals of the same group reporting the same federal tax identification number only once per the specified time period.
UnitedHealthcare Medicare Advantage Coverage Summary Updates (P 27)
- For complete details on the policy updates listed in the following table, please refer to the May 2016 Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.
UNITEDHEALTHCARE MILITARY AND VETERANS (P 28)
- Updates Not Applicable in Michigan
UNITEDHEALTHCARE AFFILIATES (P 31)
- Updates Not Applicable in Michigan