JULY 2024 UHC UPDATES
For the following plans: Medicaid, Medicare, Commercial & Exchange
New prior authorization requirements for Continuous Glucose Monitors
Applies to UnitedHealthcare Medicare Advantage plans
Beginning Sept. 1, 2024, UnitedHealthcare® Medicare Advantage plans, including Medicare and Medicaid Dual Special Needs Plans (D-SNPs), will require prior authorization for personal long-term continuous glucose monitors (CGMs) for members with any diagnosis other than Type 1 diabetes. When the durable medical equipment (DME) vendor receives a physician order for a CGM, the DME provider must obtain prior authorization for both the device and the supplies. The prior authorization will be effective for a consecutive 12-month period.
This aligns with the Centers for Medicare & Medicaid Services Local Coverage Determination (LCD) L33822. It allows members who require insulin or have problematic hypoglycemia to appropriately receive a CGM in accordance with Medicare guidelines.
In addition, this requirement doesn’t apply to members with Type 1 diabetes because these members meet the clinical criteria for CGMs. Providers don’t need to request prior authorization to fill CGM and supply orders for these patients. If a DME provider submits a prior authorization for a CGM for a member with Type 1 diabetes, they’ll receive a message that prior authorization isn’t necessary. Click for more info New prior authorization requirements for CGMs | UHCprovider.com.
Updates to oncology and hematology prior authorization codes for many plans
Applies to UnitedHealthcare Michigan Individual Exchange Plans
Effective Oct. 1, 2024, we’ll require prior authorization for specific services administered in outpatient settings as treatment for oncologic or hematologic conditions. This applies to the Healthcare Common Procedure Coding System (HCPCS) codes. We’re making this change to reflect the new codes introduced by the Center for Medicare & Medicaid Services in recent HCPCS code updates.
For all applicable codes Updates to oncology and hematology prior authorization codes for many plans | UHCprovider.com.
Michigan: Prior authorization updates for provider administered medications
Beginning Oct. 1, 2024, we will require prior authorization and notification for certain provider administered medications for UnitedHealthcare Community Plan members in Michigan. If we don’t receive a prior authorization request before the date of service, we’ll deny the claim and you won’t be able to balance bill members.
View the list of impacted drugs and their HCPCS codes in the table Michigan: Prior authorization updates for provider administered medications | UHCprovider.com.
July 2024 Preferred Lab Network list is now available
The Preferred Lab Network consists of currently contracted independent, freestanding laboratory care providers that have met higher standards for access, cost, data, quality and service, based on a rigorous application and review process. We’ll work with these distinguished labs to continue our efforts to improve the care provider and member experience.
The following labs will continue to be a part of the Preferred Lab Network for UnitedHealthcare commercial plans, UnitedHealthcare Community Plans and UnitedHealthcare® Medicare Advantage plans for the period starting on July 1:
Full test menu
- Laboratory Corporation of America (LabCorp)
- Quest Diagnostics, Inc.
Genetic/Molecular pathology
- Myriad Genetic Laboratories, Inc.
- Natera, Inc.
- Neogenomics Laboratories, Inc.
Pathology
- AmeriPath Inc., Dermpath Diagnostics Inc.
- Clinical Pathology Laboratories, Inc.
Toxicology
- Aegis Sciences Corporation
- Millennium Health, LLC
Referring patients to these labs may help reduce their out-of-pocket costs for services, as well as lab testing costs for their employer groups.
We’ll highlight these Preferred Lab Network providers in our directories, on July 1, to make it easy for members and health care professionals to identify them. We also include Preferred Lab Network providers in our Designated Diagnostic Provider network. View our Preferred Lab Network frequently asked questions for more information.
Annual federal audit of commercial plans
You may be contacted as part of the Risk Adjustment Data Validation (RADV) audit program
In compliance with the Health and Human Services-Risk Adjustment Data Validation (HHS-RADV) program, we are required to provide supporting medical documentation to support the review of the medical encounter(s) for UnitedHealthcare members. UnitedHealthcare members who are covered under individual and/or small group plans are included in this audit.
Beginning in July, we will be reaching out to randomly selected providers to gather the medical records for members selected within a specific range of 2023 service date(s). Since only a select number of members are randomly selected for the audit, not all providers will receive this request. For additional info Annual federal audit of commercial plans | UHCprovider.com.
Add your merchant ID in My Practice Profile
The UnitedHealthcare Care Cash program offers members the option to pay for their medical services with an employer-granted Mastercard® debit card. The card processes transactions like other debit or credit cards, so a merchant ID (MID) is required. To help, you can add it to My Practice Profile.
How to identify your merchant ID
This is a unique 15-digit (numeric or alphanumeric) code provided by a payment processor for debit and/or credit card payments. You can find your 15-digit MID in these 3 locations:
- Monthly bank statement
- Merchant account statement
- Credit card payment terminal (at the front desk)
Please click on the link to complete your profile Add your merchant ID in My Practice Profile | UHCprovider.com.
Complete special needs plan MOC training by Dec. 31
The Centers for Medicare & Medicaid Services (CMS) requires all special needs plans (SNPs) to provide initial and annual Model of Care (MOC) training to network providers that are contracted to see SNP members and out-of-network providers who routinely see SNP members. As a company that offers SNPs, we’re required by CMS to help you meet this requirement by providing this training to you. We offer our SNP MOC training as a 10-minute, self-paced course. Completion of training is encouraged prior to engaging with SNP members. The deadline for training completion is Dec. 31.
Digital Solutions
UnitedHealthcare Provider Advocate Account Managers or Digital Solutions Specialist may reach out to your offices by email or phone. They are reviewing internal digital to call ratio data, to identify potential candidate for our Strategic Digital Adoption Initiative, which potentially save you time and money. They can offer assistance with portal usage or trainings and find ways to reduce the calls placed to the provider service line. Another digital option is our free Application Programming Interface (API) digital solution. API makes it easier and faster to securely get comprehensive, detailed data and integrate information from multiple sources. You’ll experience fewer workflow interruptions, less manual entry, and more task automation.
If you want to learn more about our API services, please feel free to visit the resources below at your convenience.
- API Marketplace (All things API including getting started documentation, technical guides, swagger, and sandbox)
- Digital Solutions Comparison Guide: API, EDI and the UnitedHealthcare Provider Portal (Comparison of current digital solutions)
Policy and protocol updates See the updates
July 2024 updates for the following plans: Medicare, Medicaid, Exchanges and commercial.
Questions? We're here to help.
Connect with us through chat 24/7 in the UnitedHealthcare Provider Portal. For additional contact information, visit our Contact us page.