net work bulletin Network Bulletin: September 2013 - Volume 57

Transcription

Network Bulletin: September 2013 - Volume 57
network bulletin
An important message from UnitedHealthcare to health care professionals and facilities
UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making
the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network
Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information.*
*Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law
Table of Contents
Click on any of the article titles below to go directly to the article you wish to read.
Front & Center
•
UnitedHealthcare
Medicare Solutions
•
•
2014 Medicare Advantage Service Area
Reductions and Member Disenrollments
•
Member Outreach Program for
Medicare Members Extends Reach
•
UnitedHealthcare Medicare Advantage
Coverage Summary Updates
•
Concierge Medicine Practices
Florida Providers Only: UnitedHealthcare
Prior Authorization Requirement for
Commercial Benefit Plans – Outpatient
Injectable Chemotherapy
•
Announcing Neonatal Resource
Services Guidelines
•
UnitedHealth Premium®
Designation Assessment Update
•
IMRT Data Collection Forms Updated
on UnitedHealthcareOnline.com
•
Optum Cloud Dashboard and Claim
Reconsideration With Attachments
Application are Here!
UnitedHealthcare
Reimbursement Policy
•
New Prior Authorization Requirement
for Ventricular Assist Devices
•
•
Health Benefit Exchanges
•
Preventive Care Update
•
Essential Health Benefits and
Member Out-of-Pocket Update
•
2
UnitedHealth Premium® Specialty Centers
Program and Hospital Comparison
Program – Status of Programs
UnitedHealthcare
Commercial
ACP Depression Care Guide Now
Available to Primary Care Providers
•
Administration of Routine Vision
Benefits to Transition to Spectera
•
Register Now to Start Receiving
Online Member Payments
•
UnitedHealthcare Medical Policy, Drug
Policy, Coverage Determination Guideline
and Utilization Review Guideline Updates
New Reimbursement Policy: Name Change
for Physicians Billing Non-physician Health
Care Professional Medicine Services Policy
•
Update Regarding Revision to the
Physical Medicine and Rehabilitation:
Speech Therapy Policy
•
Procedure to Modifier Policy Revised
•
Revision and Renaming of the
Laboratory Rebundling Policy
UnitedHealthcare
Community Plan
•
Community Plan Prior Authorization
Requirement for Outpatient
•
Florida Providers Only: UnitedHealthCare
Community Plan Change in Ambulatory
Grouper Rates From 1-9 to 1-14
•
For MississippiCAN and Mississippi CHIP
Providers: UnitedHealthcare Community
Plan Now Offers E-prescribing
•
Health Care Reform Medicaid PCP
Increase Implementation Update
For more information call 877.842.3210, or visit UnitedHealthcareOnline.com
Table of Contents
Click on any of the article titles below to go directly to the article you wish to read.
UnitedHealthcare
Military & Veterans
•
•
2014 UnitedHealthcare Military &
Veterans TRICARE Provider Handbook
Available – October 1, 2013
A Message From UnitedHealthcare
Military & Veterans Program Integrity Team
Doing Business Better
•
3
Effective July 31, 2013: Change to
DME Provider Network
UnitedHealthcare Pharmacy
•
SignatureValue™ Benefit
Interpretation Policy Updates
•
UnitedHealthcare Consolidated
Pharmacy Benefit Program
•
UnitedHealthcare of the River Valley
Preauthorization List and Policy Updates for
Commercial and hawk-i Members Only
•
Synagis® (palivizumab) Procurement
Process for the 2013-14 RSV Season
Odds and Ends
Clinical Update
•
Effective Dec. 1: Online Clinical
Submissions to be Required
•
Clinical Practice Guidelines
•
Coordination of Care Between PCPs
and Specialists
•
Cardionet Joins Network of Providers Offering
Outpatient Cardiovascular Monitoring
•
Gordian Medical Technologies Joins Network
of Medical Supply Providers
UnitedHealthcare Affiliates
•
Health Management Programs
•
•
Training Sessions for Electronic Solutions
Neighborhood Health Partnership
Prior Authorization Requirement –
Outpatient Injectable Chemotherapy
•
Forms More Accessible Now on
UnitedHealthcareOnline.com
•
Oxford Medical and Administrative
Policy Updates
•
Electronic Inpatient Admission Notifications
•
SignatureValue™ Medical Management
Guideline Updates
•
Optum Bank Offers Loans to Providers
•
UnitedHealthcare Adoption of
Administrative Simplification Operating
Rules for Electronic EFT and ERA
•
EPS Data Packages for Faster
Downloads Now Available
Front & Center
UnitedHealth Premium® Specialty Centers
Program and Hospital Comparison Program –
Status of Programs
UnitedHealthcare has made the decision to discontinue the
UnitedHealth Premium® Specialty Centers program and the
Hospital Comparison Program, effective January 1, 2014.
When the programs end, we
will no longer display specialty
center designations or hospital
quality and cost results on our
consumer websites. We have
notified facilities and hospitals
impacted by these changes. Due
to the voluntary nature of the
UnitedHealth Premium Specialty
Centers program, the number of
facilities participating in the program
has significantly diminished and
the program is no longer ideal to
support consumer display or tiered
benefit product needs.
need for the cost portion of the
Hospital Comparison Program.
Analysis is currently underway for
hospital quality information sources
to complement the cost information
in consumer tools.
Please contact us at
866-270-5588 or by e-mail at
[email protected]
(Specialty Centers Program)
or [email protected] (Hospital
Comparison Program) if you
have any questions.
The addition of inpatient facility
cost information in the Health Care
Cost Estimator has eliminated the
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Front & Center
Announcing Neonatal Resource
Services Guidelines
Each year Neonatal Resource Services (NRS), a division of Optum, which is part
of UnitedHealthGroup, convenes an expert panel of neonatologists to review Optum’s clinical guidelines.
At the April 2013 expert panel meeting, we reviewed
evidence-based clinical guidelines for: neonatal sepsis,
apnea and bradycardia, feeding, neonatal abstinence
syndrome, thermoregulation, and discharge planning.
The guidelines are used by our case managers and
medical directors to optimize the neonatal intensive care
unit (NICU) stay and are based on a review of relevant
neonatal literature with a focus on key clinical milestones
to ensure safe discharges.
2
You can find the new NRS guidelines
by using the following links:
• Apnea and Bradycardia
• Discharge Planning
• Feeding the Neonate
• Neonatal Abstinence Syndrome
• Neonatal Sepsis
• Thermoregulation
Front & Center
UnitedHealth Premium® Designation
Assessment Update
Please watch for
your 2014 Premium
designation assessment
results. Physicians and
practice administrators
who are in markets
where the program is
available and practice
in one of the 26
Premium-eligible medical
specialties will receive
their results later this fall.
Public designation display
Time frame for claims data
Prior to the public display of the assessment results on
our consumer websites, we will provide ample time for
you to review your assessment results and consider
reconsideration, if applicable. Public designation display
of the results will occur in 2014.
The updated Premium designations are based on an
updated methodology and a new time frame of paid
claims (January 1, 2010 - February 28, 2013).
Assessment reports
To access your assessment results and review how
your practice compares with national standards for
quality and local specialty-specific cost efficiency
benchmarks, visit UnitedHealthcareOnline.com and
select “UnitedHealth Premium” on the top navigation bar.
On the site you will find a Report User Guide to help get
you started.
Resources
Go to UnitedHealthcareOnline.com and select
“UnitedHealth Premium” on the top navigation bar.
Here you will find resources and tools including the
program’s methodology, FAQ, registration information
and reconsideration materials.
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New Specialties
• General Surgery
• General Surgery - Colon/Rectal
• Ophthalmology
• Ear Nose Throat (ENT)
• Urology
*Note: Infectious disease specialists will not be included in the 2014 Premium
program. Notification has been sent to these physicians.
Further Information:
Go to UnitedHealthcareOnline.com and select
“UnitedHealth Premium” on the top navigation bar to
find resources and tools that explain the program.
Or call 866-270-5588.
Front & Center
IMRT Data Collection Forms Updated on
Based on changes to UnitedHealthcare’s medical policy for Intensity Modulated
Radiation Therapy (IMRT), we have updated the Intensity Modulated Radiation
Therapy (IMRT) Data Collection Forms.
The new forms can be found at
UnitedHealthcareOnline.com > Clinician Resources
> Cancer-Oncology > Intensity Modulated Radiation
Therapy > Related Links.
The most efficient way to submit a prior authorization
for IMRT services is by completing the appropriate
IMRT Data Collection Form, attaching relevant clinical
information. IMRT cases submitted without a completed
IMRT Data Collection Form may require additional
review time.
the necessary clinical information for a timely review.
The initial submission of complete information using the
UnitedHealthcare IMRT Data Collection Form benefits
you and our members.
If you have feedback regarding the
IMRT Data Collection Form, please send
an email to [email protected].
If we do not receive the necessary information, a
coverage decision may be based on incomplete
information. Submission of clinical records without a
completed IMRT Data Collection Form rarely provides
4
Front & Center
Optum Cloud Dashboard and Claim Reconsideration
With Attachments Application are Here!
Now you can use the Optum Cloud Dashboard website to submit reconsideration
requests with attachments for Commercial, UnitedHealthcare Medicare Solutions,
Oxford, UnitedHealthcare West and UnitedHealthcare Community Plan
claims1. Later this year Optum Cloud Dashboard will become your gateway to
UnitedHealthcareOnline.com.
If you are a UnitedHealthcareOnline.com
Standard User, ask your Password Owner
(the person who approved your access to
UnitedHealthcareOnline.com) or ID Administrator
to register for Optum Cloud Dashboard and start
your set-up process. Once the set-up is completed
on your behalf, you will receive an email from
[email protected] inviting you to complete your
registration. For assistance, please refer to our
Tips and the Standard User Quick Reference Guide.
If you are a UnitedHealthcareOnline.com
Password Owner or ID Administrator,
it’s important that you register first for Optum Cloud
Dashboard so that others in your practice or facility
will be able to register. Get started by logging into
UnitedHealthcareOnline.com and click User ID and
Password Management. For assistance, please
refer to our Tips and the Administrator
Quick Reference Guide.
Continued >
5
Front & Center
Optum Cloud Dashboard and Claim Reconsideration
With Attachments Application are Here!
< Continued
For more information about Optum Cloud
Dashboard, click here. For assistance with
registration, please call the Optum Cloud
Support Center at 855-819-5909 (Monday
through Friday, 7 a.m. to 9 p.m. CST) or email
[email protected]. We are also
offering webcast training sessions about
Multi-TIN Access, Registration & Provider Managed
Security and the Claim Reconsideration with
attachments application.
UnitedHealthcare and Optum, a leading
information and technology-enabled health
services business, are using cutting edge cloud
technology to drive change and improvements in
revenue cycle processes. Strategic collaboration
between UnitedHealthcare and physicians,
hospitals and other health care facilities allows
testing of solutions that streamline and simplify
the administrative experience.
6
If a state has specific provider dispute or appeal
rights, then items received through Optum Cloud
Dashboard will be handled and reported as a
dispute or appeal, and appropriate
acknowledgement and closure notices will be sent
according to state requirement.
The Optum Cloud Claim Reconsideration with attachments application is
not yet available for: TRICARE West, UnitedHealthcare Plan of the River
Valley, Inc. (Commercial and Community Plan) and UnitedHealthcare
Community Plan of the District of Columbia, Kansas, Louisiana, Michigan
and Nevada.
1
Front & Center
New Prior Authorization Requirement for
Ventricular Assist Devices
Effective for dates of service on or after January 1, 2014, UnitedHealthcare will
implement a prior authorization requirement for Ventricular Assist Devices (VADs)
for destination therapy and bridge-to-heart transplant indications for Commercial
and Medicare Solution Members. Noncompliant services will not be eligible
for reimbursement.
Failure of physicians and facilities to obtain
authorization or confirm that an approved
authorization is on file prior to performing the
procedure may result in claims being denied in whole
or in part If you are denied reimbursement because
of failure to obtain prior authorization, you may not
balance bill our member.
Additional information, including a list of VAD codes
requiring prior authorization will be published in
the November Network Bulletin. Please contact
your UnitedHealthcare Network Management
representative with any questions.
Facilities are responsible for Admission Notification
for inpatient services. UnitedHealthcare’s standard
appeal process will apply to any denied claims.
7
Front & Center
Health Benefit Exchanges
As a requirement of the Patient Protection and Affordable Care Act (PPACA), the Health
Insurance Marketplace, also known as Exchanges, must be operational in each state and
accommodate member open enrollment on Oct. 1, 2013 for the 2014 plan year.
The Health Insurance Marketplace is intended to make
it easier for individuals and small businesses with fewer
than 50 employees to compare plan offerings and buy
health insurance from certified health insurers
(Qualified Health Plans). The Health Insurance Marketplace is predicted to serve
as a gateway for an estimated 29 million people to find
health insurance.
UnitedHealthcare is looking forward to the opportunity
presented by the Health Insurance Marketplace and
believes it will be a vibrant growth market that will have
much to offer consumers. As we continue to evaluate
opportunities and make decisions regarding our
participation in the marketplace, we will provide notice
on a state-by-state basis.
While the marketplace will be the main method to
purchase health insurance and enroll in public programs
such as Medicaid and CHIP, people will also continue to
get coverage from their employer, just as they do now.
8
Front & Center
Under the Patient Protection and Affordable Care Act (PPACA), members in nongrandfathered health plans may receive certain preventive care services, based upon age,
gender and other factors, without cost-sharing.
These preventive services must be provided by
physicians and health care professionals within the
plan’s network. As a result, over the coming months,
UnitedHealthcare will expand or change our coverage
of certain preventive care services, including over-thecounter medication coverage, BRCA genetic testing for
breast cancer and breast feeding supplies.
Over-the-counter medication coverage
The United States Departments of Labor, Health and
Human Services, and the Treasury issued a series of
Frequently Asked Questions (FAQs) earlier this year
related to preventive care under PPACA. The FAQs
clarified the Departments’ stance on covering certain
over-the-counter (OTC) medications and contraceptives
without cost-share when prescribed by a health care
professional and filled at a network pharmacy. We are
in the process of updating our systems to accommodate
this change effective Nov. 1, 2013.
UnitedHealthcare will cover certain OTC drugs and
contraceptives for women, including aspirin, folic acid
supplements for women, fluoride and iron supplements
for children and vitamin D supplements for older adults.
OTC contraceptives for women include female condoms
and contraceptive film, foam and gel. The drugs on
our new Preventive Care Medications List are covered
at 100 percent when age- and gender-appropriate,
prescribed by a health care professional and filled at a
network pharmacy.
Our revised Preventive Care Medications List
will be ready Nov. 1, 2013 and posted on
UHCWest.com and UnitedHealthcareOnline.com.
Continued >
9
Front & Center
< Continued
BRCA genetic testing
UnitedHealthcare covers BRCA genetic counseling and
evaluation for BRCA testing today without cost-share as
recommended by the current U.S. Preventive Services
Task Force (USPSTF) and listed in our Preventive Care
Services Coverage Determination Guideline. In April
2013, the USPSTF released a draft recommending the
BRCA test for women over age 18 without a cancer
history who may be at increased risk for BRCA-related
cancer, as defined by their family history, nationality or
other factors.
In response to the USPSTF draft recommendation,
UnitedHealthcare will cover the BRCA test without costshare beginning Oct. 1, 2013 for women over age 18 at
risk for BRCA-related cancer and who have not been
diagnosed with breast or ovarian cancer, subject to prior
authorization. The test will be covered in full with prior
authorization. As before, UnitedHealthcare will continue
covering BRCA testing for women and men at risk with
a history of cancer who meet other testing guidelines as
provided by their benefit plan. UnitedHealthcare strongly
recommends that women who believe that they should
have the BRCA test done obtain genetic counseling.
Breast-feeding supplies
PPACA gives pregnant and postpartum women access
to comprehensive lactation support and counseling and
breast-feeding equipment without cost-sharing. Breastfeeding support, supplies and counseling must be
received by a network provider, during pregnancy and/or
in the postpartum period.
Since many members may prefer to purchase a more
portable and convenient electric breast pump rather
than rent hospital-grade equipment (heavy-duty breast
pumps designed for multiple users), effective Jan. 1,
2014, UnitedHealthcare will only cover the purchase of
personal, double-electric breast pumps.
In February 2013, the Health Resources and Services
Administration (HRSA) guidelines related to breastContinued >
10
Front & Center
< Continued
feeding support were clarified to indicate that plans may
cover the costs of purchasing, instead of renting, breastfeeding equipment without cost-share.
Double-electric breast pumps often provide a better
experience for the mother and help encourage breastfeeding because they are portable and more convenient.
Studies also show that due to the variability in breast
pumps, high-quality, personal use double-electric breast
pumps are as effective as, or potentially more effective
than hospital-grade pumps in outpatient settings.*
UnitedHealthcare members who are renting a
hospital-grade breast pump at the time of the
Jan. 1, 2014 effective date may continue to do so.
* Methods of milk expression for lactating women review by The Cochrane
Collaboration, published in The Cochrane Library, 2011, Issue 12.s.
.
11
Front & Center
Essential Health Benefits and
Member Out-of-Pocket Update
The Patient Protection
and Affordable Care
Act (PPACA) requires
insurers to provide
coverage for an Essential
Health Benefits (EHB)
package in ten benefit
categories, effective the
first plan year on or after
Jan. 1, 2014 for most
Small Group (insured)
and Individual policies.
Three things to know about Essential
Health Benefits:
1. All member cost share amounts for EHB must
accumulate to the out of pocket maximum (OOPM),
including deductibles, co-insurances and copays.
Submitted claims and encounters must include
member cost share amounts. Once the out of pocket
maximum is met, there is no longer a need to collect
cost share amounts including copays.
For more information, visit UHC.com
> United for Reform Resource Center > Health
Reform Provisions > Essential Health Benefits
2. Most dental, vision and habilitative services will
be covered under UnitedHealthcare medical plans
affected by the EHB provision. State definitions of
EHB will vary and may require product adjustments.
3. There are no annual dollar and lifetime dollar limits
for eligible services. We removed lifetime dollar
limits and annual dollar limits in 2010, and will
continue to make any adjustments required as a
result of each state’s determination of EHB.
12
Front & Center
ACP Depression Care Guide Now Available to
Primary Care Providers
At UnitedHealthcare, we
know that primary care
providers often are the
first to recognize the signs
of depression in patients.
That’s why we want you to
know about the American
College of Physicians’
Depression Care Guide
that is now available.
13
It offers concise, practical information and strategies
to help busy clinicians reduce treatment gaps for
depression in ways that suit your own practice setting.
And for those who read the guide and respond to a
40-question quiz, there is an opportunity to qualify for:
•
Up to six AMA PRA Category 1 Credits™ - available
until Dec. 15, 2014 to internists, family practitioners
or psychiatrists
•
Up to six hours of AAPA Category 1 CME credits
approved by the Physician Assistant Review Panel
until Dec. 15, 2013 if you are a physician assistant
•
Continuing education available until Dec. 15, 2013.
If you are a psychologist, consult with your local
health care system, institution, or licensing board
to determine if this course can be used to earn
continuing education credit. Access to
psychology licensing boards in the
United States and Canada is available at:
http://www.kspope.com/licensing/index.php.
•
Up to six continuing education contact hours
approved by the Pennsylvania State Nurses
Association and available until Dec. 15, 2013
if you are a registered nurse or nurse
practitioner (this approval does not apply in
Iowa and California.)
The guide was created by a committee of 13 leading
specialists in depression and is organized to help you
readily access the specific topics that are most important
to you, whether you are an internist, family practitioner,
psychiatrist, psychologist, physician assistant, nurse
practitioner, or nurse.
The Depression Care Guide is free to all health care
professionals and you do not need to be an ACP
member to create an account.
To access the guide, go to www.acponline.org and
select “CME” from the drop-down menu, then “ACP
Depression Care Guide”.
Front & Center
Administration of Routine Vision Benefits
to Transition to Spectera
UnitedHealthcare will begin to transition the administration of routine vision
benefits to Spectera Eyecare Networks in 2014.
Although this change will not happen all at once,
it means that more patients with UnitedHealthcare
medical plans will receive their eye care from
Spectera Eyecare Networks doctors. Members will
continue to use UnitedHealthcare network providers
for medical vision benefits.
Please include all appropriate diagnosis codes on
your claims in order to accurately represent both
medical and routine eye care encounters. The
reason for the patient’s visit is a criteria for eye care
coverage and claims payment. Be sure to verify
eligibility and benefits at the time of service to be
certain you are an in-network provider for each of your
patient’s benefit plans. New coverage mandated by
14
the Affordable Care Act includes an annual eye exam
and eyewear for pediatric patients. These patients will
be directed to Spectera Eyecare Networks and you
must be a contracted provider to provide this benefit.
To request network participation
with Spectera Eyecare Networks,
please visit spectera.com/providers
or call 800-638-3120.
Front & Center
UnitedHealthcare recently introduced a new online payment capability that allows
commercial members to make online payments directly to physicians, hospitals and other
facilities through the myuhc.com member portal to help you get paid faster and balance
your accounts receivable.
UnitedHealthcare has contracted with InstaMed, a
leading Healthcare Payments Network, to process and
distribute the payments directly to providers. InstaMed is
certified and audited at the highest levels for both health
care and payment processing by Payment Card Industry
(PCI), Electronic Healthcare Network Accreditation
Commission (EHNAC), and the Health Insurance
Portability and Accountability Act (HIPAA).
With online Member Payments, UnitedHealthcare
commercial members manage and pay claims for
their providers online from myuhc.com, a feature
our members have told us they want.
15
Member Payments is an effective, efficient solution for
providers and members. By registering with InstaMed to
receive online member payments, you can enjoy:
•
Automatic payments deposited electronically
into your preferred bank account
•
Faster payments to reduce accounts
receivable balances
•
Reduced time and costs to collect payments
•
Payments posted automatically to a variety of
practice management systems
•
Real-time payment reports available 24/7
•
Increase payments and reduce bad
debt by accepting a convenient patient
payment method
Continued >
Front & Center
< Continued
There are no sign-up or monthly fees to register for
Member Payments. As a registered provider, you pay
a simple, flat rate that is similar to what you pay today
when patients pay with their preferred payment cards
or bank accounts. And if you are an existing provider on
the InstaMed Payments Network, you’ll pay your current
contracted fees.
You can register for and get more
information about online Member Payments at
https://register.instamed.com/uhc
or by calling 215-789-3682. InstaMed representatives
will be available to help you with the registration
process if you have questions.
If you have additional questions, please contact your
Physician or Hospital Advocate.
16
UnitedHealthcare Commercial
Prior Authorization Requirement for
Commercial Benefit Plans – Outpatient
Effective fourth quarter, 2013, UnitedHealthcare
will require all Florida participating network
providers to obtain prior authorization
when administering chemotherapy drugs to
UnitedHealthcare commercially insured members
in an outpatient setting.
Details on this protocol and how to obtain a prior authorization
will be included in a future Network Bulletin and letters were sent to
impacted providers.
UnitedHealthcare uses the National Comprehensive Cancer Network
(NCCN) Drugs & Biologics Compendium™ in reviewing requests and
making chemotherapy coverage decisions.
17
UnitedHealthcare Commercial
UnitedHealthcare Medical Policy, Drug Policy, Coverage
Determination Guideline and Utilization Review Guideline Updates
For complete details on the
new and/or revised policies and
guidelines listed in the following
table, refer to the monthly
Medical Policy Update Bulletin at
> Tools & Resources > Policies,
Protocols and Guides > Medical
& Drug Policies and Coverage
Determination Guidelines >
Medical Policy Update Bulletin.
Policy Title
Policy Type
Effective Date
Policy Update
Bulletin
Chromosome Microarray Testing
Medical Policy
Oct. 1, 2013
Sept. 2013
Clinical Trials
Coverage Determination
Guideline
Jan. 1, 2014
Sept. 2013
Clotting Factors and Coagulant Blood Products
Drug Policy
Oct. 1, 2013
July 2013
Aug. 2013
Sept. 2013
Cost Effective Quality of Care Guideline
Quality of Care Guideline
Aug. 1, 2013
July 2013
Anemia Drugs (Darbepoetin Alfa and
Epoetin Alfa)
Drug Policy
Sept. 1, 2013
Aug. 2013
Botulinum Toxins A and B
Drug Policy
Oct. 1, 2013
Sept. 2013
NEW
UPDATED/REVISED
Continued >
18
< Continued
UnitedHealthcare
Commercial
UnitedHealthcare
Medical Policy, Drug
Policy, Coverage
Determination
Guideline and
Utilization Review
Guideline Updates
Policy Title
Policy Type
Effective Date
Policy Update
Bulletin
Chemotherapy Observation or
Inpatient Hospitalization
Utilization Review Guideline
Aug. 1, 2013
July 2013
Durable Medical Equipment and Related
Supplies, Prosthetics and Orthotics
Utilization Review Guideline
Aug. 1, 2013
July 2013
Gastrointestinal Motility Disorders, Diagnosis
and Treatment
Medical Policy
Aug. 1, 2013
July 2013
High Frequency Chest Wall Devices
Medical Policy
Sept. 15, 2013
Aug. 2013
Human Immunodeficiency Virus (HIV)
Tropism Testing
Medical Policy
Aug. 1, 2013
July 2013
Omnibus Codes
Medical Policy
Aug. 1, 2013
July 2013
Sept. 1, 2013
Aug. 2013
Panniculectomy and Body
Contouring Procedures
Guideline
Oct. 1, 2013
Sept. 2013
Pectus Deformity Repair
Guideline
Oct. 1, 2013
Sept. 2013
Preventive Care Services
Guideline
Aug. 1, 2013
July 2013
Oct. 1, 2013
Aug. 2013
Sept. 2013
Aug. 1, 2013
July 2013
Private Duty Nursing
Guideline
Continued >
19
< Continued
UnitedHealthcare
Commercial
Policy Title
Policy Type
Effective Date
Policy Update
Bulletin
Surgical and Ablative Procedures for Venous
Insufficiency and Varicose Veins
Guideline
Oct. 1, 2013
July 2013
Aug. 2013
Sept. 2013
Synagis (Palivizumab)
Drug Policy
Sept. 1, 2013
Aug. 2013
Medical Policy
July 1, 2013
July 2013
REPLACED/RETIRED
UnitedHealthcare
Medical Policy, Drug
Policy, Coverage
Determination
Guideline and
Utilization Review
Guideline Updates
20
Transthoracic Echocardiography
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service
or procedure. In the event of an inconsistency or conflict between the information provided in this Bulletin and the posted policy, the
provisions of the posted policy will prevail.
UnitedHealthcare Reimbursement Policy
Unless otherwise noted, these reimbursement policies apply to services
reported using the 1500 Health Insurance Claim Form (CMS-1500) or its
electronic equivalent or its successor form. UnitedHealthcare reimbursement
policies do not address all factors that affect reimbursement for services
rendered to UnitedHealthcare members, including member benefit plan
documents, UnitedHealthcare medical policies and the UnitedHealthcare
Physician, Health Care Professional, Facility and Ancillary Provider
Administrative Guide. Meeting the terms of a particular reimbursement policy is
not a guarantee of payment. Once implemented the policies may be viewed in
their entirety at UnitedHealtcareOnline.com > Tools & Resources > Policies
and Protocols > Reimbursement Policies-Commercial. In the event of
an inconsistency or conflict between the information provided in the Network
Bulletin and the posted policy, the provisions of the posted policy prevail.
21
New Reimbursement Policy: Name Change for Physicians Billing
Nonphysician Health Care Professional Medicine Services Policy
The Physicians Billing Nonphysician Health Care Professional Medicine Services Policy
name has been changed to the Nonphysician Health Care Codes Policy.
As announced in the May 2013 Network Bulletin,
effective for dates of services on or after
Sept. 1, 2013, UnitedHealthcare has implemented a
new policy denying reimbursement of nonphysician
health care codes when reported by physicians.
Supported by CPT coding guidelines, physicians
should report evaluation and management (E/M)
services (CPT codes 99201-99499) instead of the
following medicine codes which are intended for use
by nonphysician health care professionals:
22
•
Medical genetics and genetic counseling
services (CPT code 96040)
•
Health and behavior assessment/intervention
(CPT codes 96150-96155)
•
Medical nutrition therapy (CPT codes 9780297804, HCPCS codes G0270-G0271)
•
Education and training for patient selfmanagement (CPT codes 98960-98962)
Procedure to Modifier Policy Revised
– Additional Modifiers Being Added Update Regarding Revision
to the Physical Medicine and
Rehabilitation: Speech
Therapy Policy An article published in the March Network
Bulletin announced that the Physical
Medicine and Rehabilitation: Speech
Therapy Policy would be revised late
in the second quarter of 2013 to deny
reimbursement for CPT codes 9920199499 when reported by speech language
therapists/pathologists. That policy change
was delayed and will now be implemented in
the third quarter of 2013. We apologize for
any confusion caused by this delay.
23
Modifiers AU, AV, BA, BO, PT, and TH will be addressed
through the revised Procedure to Modifier Policy and
added to the Procedure to Modifier List.
In accordance with correct coding, UnitedHealthcare will consider
reimbursement for a procedure code/modifier combination only when the
modifier has been used appropriately. The changes will occur in the fourth
quarter of 2013.
Revision and Renaming of the
Laboratory Rebundling Policy
To align with the Centers for Medicare and Medicaid Services (CMS)
guidance related to qualitative drug screening codes, UnitedHealthcare
will require the use of HCPCS codes G0431 and G0434 to report drug
screen testing. We will no longer reimburse CPT codes 80100, 80101,
and 80104 for these services.
For more information on reporting these codes, please go to
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNMattersArticles/downloads/SE1105.pdf
In addition, the Laboratory Rebundling Policy will be renamed as the
Laboratory Services Policy, which more accurately reflects the services
addressed in the policy.
These changes will occur in the first quarter of 2014.
24
UnitedHealthcare Medicare Solutions
2014 Medicare Advantage Service Area
Reductions and Member Disenrollments
About five percent of our UnitedHealthcare Medicare Advantage
members across the country will be impacted by service area
reductions in 2014. These members will receive an official nonrenewal notice from UnitedHealthcare by Oct. 2, 2013.
The non-renewal notice will give
members information about their
special election period eligibility for
2014 coverage and their Medicare
Supplement guaranteed rights, as
well as replacement plans for all
Medicare Advantage organizations
and Prescription drug plan sponsors
available in their area.
In most cases, these members
will receive additional outreach by
phone or mail to inform them of
other health plan options offered by
UnitedHealthcare.
The majority of providers and facilities
contracted for UnitedHealthcare
Medicare Advantage products will
25
not be affected by these changes. In
most areas, we will still offer networkbased Medicare Advantage plans,
so provider contracts will remain in
place. In markets where contracts are
affected, UnitedHealthcare Network
Account Managers will contact
providers with more details.
To learn more, please visit
> Tools & Resources > Products
& Services > Medicare >
UnitedHealthcare Medicare, or
contact your local Network Account
Manager or Provider Advocate.
Member Outreach Program for
Medicare Members Extends Reach
Our outreach program focused on improving quality of care for our Medicare
Solutions members has expanded and is now operating nationwide. Please note
that you may see an increase in office visits due to this initiative.
During telephone outreach calls, Optum health advocates and nurses educate members
about preventive care, screenings and medication adherence. They encourage members to
make doctor appointments to close their gaps in care and can even help members to arrange
transportation to appointments. Our health advocates and nurses are trained to ask the questions
that will help identify why the member has not sought care in an effort to provide them the specific
information that they can best relate to. Our nurses can even answer some clinical questions.
The multi-state initiative began in six states in the Northeast.
26
UnitedHealthcare Medicare Advantage
Coverage Summary Updates
The following UnitedHealthcare
Medicare Advantage Coverage
Summaries were revised on
June 24, 2013. A detailed summary
of the updates is available at
> Tools & Resources > Policies,
Protocols and Guides >
UnitedHealthcare Medicare
Advantage Coverage Summaries
> Medicare Advantage Coverage
Summary Updates: July 2013.
Title
Breast Reconstruction Following Mastectomy
Cardiac Pacemakers and Defibrillators
Dialysis Services
Gastroesophageal and Gastrointestinal (GI) Services and Procedures
Positron Emission Tomography (PET)/Combined PET-CT (Computed Tomography)
Preventive Health Services and Procedures
Respiratory Therapy, Pulmonary Rehabilitation and Pulmonary Services
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or procedure.
27
Concierge Medicine Practices
Physicians who have signed a standard
UnitedHealthcare Physician Agreement
have agreed to not engage in a concierge
medicine practice.
Additionally, page 76 of the Commercial and
Medicare Advantage Administrative Guide,
which is incorporated into the agreement,
states the following:
Additional fees for covered services
Specifically, the agreement states the following:
“You will not charge our customers anything for the
services you provide, if those services are covered
services under their benefit contract, but the applicable
copay, coinsurance or deductible amount. If the services
you provide are not covered under our customer’s
benefit contract, you may bill our customer directly. You
will not require a customer to pay a “membership fee”
or other fee in order to access you for covered services
(except for co-payments, coinsurance and/or deductibles
provided for under the customer’s benefit contract) and
will not discriminate against any customer based on the
failure to pay such a fee.”
28
You may not charge our Customers fees for covered
services beyond copayments, coinsurance or
deductibles as described in their benefit plans. You may
not charge our Customers retainer, membership, or
administrative fees, voluntary or otherwise. This includes,
but is not limited to, concierge/boutique practice fees.
Lastly, CMS has published articles as well
advising that “when participating providers request any
other payment for covered services from Medicare
patients they are liable for substantial penalties and
exclusion from Medicare and other Federal health
care programs.”
UnitedHealthcare Community Plan
Florida Providers Only:
UnitedHealthcare Community Plan Prior
Authorization Requirement for Outpatient
Effective in the fourth quarter
of 2013 UnitedHealthcare
Community Plan will
require all Florida providers
administering chemotherapy
on an outpatient basis to
UnitedHealthcare Community
Plan members in Florida to
obtain prior authorization.
Details on how to obtain prior
authorization will be included in a
future Network and letters sent to
impacted providers.
UnitedHealthcare’s drug policy
which supports coverage based
upon the National Comprehensive
Cancer Network Drugs & Biologics
Compendium™ will be used for
coverage determination.
29
Florida Providers Only:
UnitedHealthCare Community
Plan Change in Ambulatory
Grouper Rates from 1-9 to 1-14
UnitedHealthCare Community Plan has
implemented the 1-14 payment group
rates for ambulatory surgical centers
(ASCs) effective September 1, 2013
for participating ASCs in Florida. This
new rate is aligned with current Agency
for Healthcare Administration (AHCA)
reimbursement methodology. Should
you have any questions, please feel
free to contact your local Network
Account Manager.
For MississippiCAN and Mississippi CHIP Providers:
UnitedHealthcare Community Plan Now Offers E-prescribing UnitedHealthcare
Community Plan now
offers e-prescribing
for MississippiCAN
and Mississippi CHIP,
which allows prescribing
physicians and other
qualified health care
professionals to
electronically send
prescriptions directly to
a pharmacy from the
place of service.
The program provides the following advantages:
1. Added convenience.
Instead of writing a paper prescription, a physician or
other health care provider can enter the prescription
directly into an electronic health record or practice
management system using a secure network – the
Pharmacy Health Information Exchange™ operated
by Surescripts®. This program also allows physicians
and other health care professionals to verify member
eligibility, medication history, and check the list of
covered medications prior to writing a prescription.
2. E-prescribing can help reduce preventable
medication errors while optimizing
members’ prescription drug benefits. A 2006 study from the Center for Information
Technology Leadership estimates that electronic
prescribing with clinical decision support has the
potential to reduce preventable adverse drug events
by more than 60 percent. Since it eliminates the
need for handwritten prescriptions and phone and
30
fax communications between physicians
and pharmacies, it can reduce the risk of having
a prescription misinterpreted.* UnitedHealthcare’s
e-prescribing program also automatically checks for
potentially dangerous drug-to-drug and drug-allergy
interactions.
3. E-prescribing provides physicians with
tools to help prescribe the most clinically
appropriate and cost-effective medication.
More than 75 percent of community pharmacies in
the U.S. currently accept e-prescriptions*.If the
patient does not want his or her prescription sent
electronically, or the pharmacy does not yet accept
e-prescriptions, a health care provider can print the
prescription for his or her patient.
For more information, or to participate in
UnitedHealthcare Community Plan’s e-prescribing
program, please call Surescripts at
866-RxReady (866-797-3239). Thank you.
Source: *http://www.cms.gov/Medicare/E-Health/Eprescribing/downloads/
e-rxreporttocongress.pdf
Health Care Reform Medicaid PCP
Increase Implementation Update
As of Aug. 1, 2013, the
Centers for Medicare
& Medicaid Services
(CMS) confirmed that
most Medicaid state
agencies have the
necessary approvals in
hand to move forward
with implementation of
the Medicaid primary
care physician (PCP)
fee increase for the
two-year period
(Jan 1. 2013 –
Dec. 31, 2014). 31
UnitedHealthcare Community Plan is working with
its state Medicaid partners to properly and promptly
implement the increased payments.
Based on reimbursement methodologies established
by your state’s Medicaid agency and approved by
CMS, UnitedHealthcare Community Plan is working
to implement the needed requirements to reimburse
providers accordingly. As a reminder, this increase
is available to participating and non-participating
physicians and mid-level providers that follow the
attestation process, as outlined by each state
Medicaid agency.
Note: All participating Medicaid state agencies have
worked to implement their own repayment process with
varying processes and requirements.
Please visit your state’s specific UnitedHealthcare
Community Plan provider page to learn more
about implementation dates and details at
UHCCommunityPlan.com or contact your local
Physician Advocate or Network Account Manager.
Be sure to review your state Medicaid agency’s website
for PCP fee increase updates. UnitedHealthcare
Community Plan continues to monitor all state activity
and will provide updates as they are available.
In most states, fee-for-service providers may either
receive reconciled payment through transactional
increases, per eligible claim submitted; or a lump sum
payment at defined intervals throughout the two-year
increase period. Capitated providers may receive
reconciled capitation payments or another form of
reimbursement for the eligible claims, as outlined by
each state’s implementation process.
UnitedHealthcare Military & Veterans
2014 UnitedHealthcare Military & Veterans
TRICARE Provider Handbook Available –
October 1, 2013
The updated edition of the UnitedHealthcare
Military & Veterans TRICARE Provider Handbook
will be available on October 1, 2013. Changes in the Handbook will be effective on January 1, 2014
for currently contracted providers and immediately for providers
contracted on or after October 1, 2013.
The TRICARE Handbook is located on
UnitedHealthcareOnline.com > Tools & Resources >
Policies, Protocols and Guides, TRICARE Provider Handbook
and UHCMilitaryWest.com > Providers > Provider Handbook.
32
Because UnitedHealthcare Military & Veterans is a federal contractor and not solely governed
by its provider contracts and policies, we, along with our contracted providers, must comply
with both general federal law and TRICARE regulations. Please be sure to familiarize yourself
with TRICARE’s federal policies and procedures in addition to your provider contract with
UnitedHealthcare Military & Veterans.
UnitedHealthcare Military & Veterans’ Program Integrity
Department provides the following programs to protect
the ethical and fiscal integrity of TRICARE and educate
beneficiaries and providers:
•
Health care fraud awareness programs
•
Easy methods for reporting health care fraud
•
Tools to help you understand health care fraud
•
Educational support if you are referred to
TRICARE Management Activity’s Program Integrity
Department for case prosecution.
Please remember that health care fraud includes not
only filing a TRICARE claim that is false or fictitious,
but any intentional deception or misrepresentation by
the provider and anyone acting on their behalf who
either knew or should have known that the deception
or misrepresentation could result in an unauthorized
TRICARE payment (see 32 CFR §199.2).
TRICARE’s definition of fraud is quite broad. Essentially
it states that providers or anyone acting on their behalf
will be held liable for fraud not only if they knew, but also
if they should have known about the fraudulent activity.
Continued >
33
< Continued
TRICARE includes a subjective standard in its definition
of fraud, ultimately increasing providers’ responsibility to
report fraud to protect themselves from being held liable
for an activity that the TRICARE Management Activity
(TMA) determines you should have known might result
in fraud.
Below are some helpful tips on fully understanding
your role as a TRICARE provider:
1. Read the TRICARE Provider Handbook,
accessible at: https://www.uhcmilitarywest.com/
uhcmw/portal/provider/overview/
As a TRICARE contracted provider, you cannot bill
TRICARE beneficiaries for anything other than their
applicable deductibles, copayments and/or costsharing amounts. (see 32 CFR §199.6(a)(11)).
3. Promptly respond to any correspondence from
UnitedHealthcare Military & Veterans’ Program
Integrity Department. A point of contact is listed
at the bottom of every correspondence from our
department if you have any questions. The easiest
way to report fraud is through our company website
at: http://uhcmilitarywest.com and click on “Report
Fraud, Waste, and Abuse”.
2. Do Not Balance Bill. Balance billing a TRICARE
beneficiary for the difference between the amount
TRICARE reimburses for a covered service and
the amount that you charged is not permitted and
may trigger a fraud investigation, recoupment or
potential referral to TMA-PI for federal prosecution.
34
Effective July 31, 2013:
Change to DME Provider Network
Philips Remote Cardiac Monitoring is no longer participating in UnitedHealthcare’s
durable medical equipment (DME) provider network for all lines of business,
effective July 31, 2013. Members who receive services provided by a non-network
DME provider may incur higher out-of-pocket expenses, depending on their
benefit plan. Please refer our members to in-network DME providers, as outlined
in your network participation agreement.
Services for cardiac monitoring and Home PT/INR can be obtained from
the following nationally contracted providers:
For cardiac monitoring services:
35
Biomedical Systems www.biomedsys.com Cardionet www.cardionet.com Lifewatch www.lifewatch.com For home PT/INR monitoring services:
800-877-6334
866-426-4402
877-774-9846
www.cardionet.com www.edgepark.com www.coaguchek.com 866-426-4402
800-321-0591
800-280-7801
Cardionet Edgepark Roche
National and local providers for these services can be found at
www.UnitedHealthcareOnline.com.
Cardionet Joins Network of Providers Offering
Outpatient Cardiovascular Monitoring
Cardionet, LLC has joined our network of providers offering outpatient
cardiovascular monitoring, Holter monitors, event monitors and mobile cardiac
outpatient telemetry to our members who meet clinical eligibility criteria across all
lines of business effective July, 1, 2013.
Cardionet also provides home PT/INR monitoring and testing. Nationally contracted cardiac monitoring providers are:
For cardiac monitoring services:
36
Biomedical Systems www.biomedsys.com Cardionet www.cardionet.com Lifewatch www.lifewatch.com Nationally contracted PT/INR providers are:
800-877-6334
866-426-4402
877-774-9846
www.cardionet.com www.edgepark.com www.coaguchek.com 866-426-4402
800-321-0591
800-280-7801
Cardionet Edgepark Roche
Gordian Medical Technologies Joins Network
of Medical Supply Providers
American Medical Technologies, dba Gordian Medical, has joined our network
of medical supply providers effective July 1, 2013 for all lines of business.
Gordian Medical provides wound care supplies such as gauze, tapes, and
bandages to our members in long-term care nursing facilities and hospices.
Nationally contracted medical supply providers are:
Byram Edgepark Gordian
Omnicare
www.byramhealthcare.com www.edgepark.com www.amtwoundcare.com www.omnicare.com 877-902-9726
800-321-0591
800-568-5514 (Nursing home only)
800-990-6664 (Nursing home only)
37
UnitedHealthcare offers case and disease management programs to support physicians’
treatment plans and assist members in managing their conditions. Using medical, pharmacy
and behavioral health claims data, our predictive model systems help us identify members
who are at high risk and directs them to our programs.
Patients can also be identified at time of hospital
discharge via a Health Risk Assessment, Nurseline
referral, or member or caregiver referral. If you have
patients who are UnitedHealthcare members who
would benefit from case or disease management,
you can refer them to the appropriate program by
calling the number on the back of the member’s
health insurance ID card.
Case Management
Participation in these programs is voluntary.
Upon referral, each member is assessed for
the appropriate level of care for their individual
needs. Programs vary depending on the member’s
benefit plan.
Specifically, our programs are designed to assist in
ensuring individuals:
At the core of case management is identifying
high-cost, complex, at-risk members who can benefit
from these services. We partner with members and their
physicians or other health care professionals to facilitate
health care access and decisions that can have a
dramatic impact on the quality and affordability of their
health care.
•
Receive evidenced-based care
•
Have necessary self-care skills and/or
caregiver resources
Continued >
38
< Continued
•
Have the right equipment and supplies to
perform self-care
•
Have requisite access to the health care
delivery system
•
Are compliant with medications and the
physician’s treatment plan
Depending on the member’s health plan and benefit
plan design, disease management programs vary and
may include:
Our case managers are registered nurses who
engage the appropriate internal, external or
community-based resources needed to address
members’ health care needs. When appropriate, we
provide referrals to other internal programs such as
disease management, complex condition management,
behavioral health, employee assistance and disability.
Case management services are voluntary and a member
can opt out at any time.
Disease Management Programs
•
Coronary Artery Disease
•
Diabetes
•
Heart Failure
•
Asthma
•
Chronic Obstructive Pulmonary Disease
•
Cancer
•
High Risk Pregnancy
•
Kidney Disease
•
Acute MI1
•
Hemophilia1
1
Limited to eligible UHC River Valley and NHP members
We offer disease management programs designed to
provide members with specific conditions the appropriate
level of intervention.
Continued >
39
< Continued
Our programs include:
•
Screening for depression and helping members
access the appropriate resources.
•
Addressing lifestyle-related health issues and
referring to programs for weight management,
nutrition, smoking cessation, exercise, diabetes care
and stress management.
•
Helping members understand and manage their
condition and its implications.
•
Education on how to reduce risk factors, maintain a
healthy lifestyle, and adhere to treatment plans and
medication regimens.
For some programs, members may receive:
40
•
A comprehensive assessment by specialty-trained
registered nurses to determine the appropriate level
and frequency of interventions.
•
Educational mailings, newsletters and tools such as
a HealthLog to assist them in tracking their physician
visits, health status and recommended targets or
other screenings.
•
Information on gaps in care and encouragement
to discuss treatment plans, goals and results with
the physician. Physicians with patients in moderate
intensity programs may receive information on their
patient’s care opportunities.
•
Transitional case management when high risk
patients are discharged from a hospital
•
Outbound calls for the highest risk individuals to
address particular gaps in care. You will be
notified when patients are identified for the
high-risk program.
These programs complement the physician’s treatment
plan, reinforce instructions you may have provided, and
offer support for healthy lifestyle choices.
For UnitedHealthcare Community Plan members:
Please refer to the UHCommunityPlan.com
Provider page to find your state-specific Provider
Administrative Manual.
Training Sessions for Electronic Solutions
We offer instructor-led
webcast training
sessions to help
automate and streamline
administrative processes.
•
•
UnitedHealthcareOnline.com Password Owner
•
UnitedHealthcareOnline.com Notification/
Prior Authorization Function Overview
•
Electronic Payments and Statements (EPS)
•
Electronic Data Interchange (EDI) 101
•
OxfordHealth.com Overview
•
Post-n-Track® Demonstration
•
PNC Remittance Advantage for Electronic
Oxford Payments and EOBs
Click to learn more about
UnitedHealthcare and Oxford sessions
and obtain registration information.
41
Forms More Accessible Now on
Session topics include:
In response to feedback received on our
annual electronic solutions survey, we’ve
created a centralized forms section on
UnitedHealthcareOnline.com > Tools & Resources
> Forms. Here you’ll find all administrative, claim,
patient, clinical and pharmacy forms. These forms
also remain available in their previous locations.
Electronic Inpatient
Admission Notifications
Use the Electronic Data Interchange (EDI) 278N to
submit notifications from your practice management
system for UnitedHealthcare, UnitedHealthcare
Medicare Solutions and UnitedHealthcare
Community Plan. For more information, go to
Admission Notification (278N), contact your
clearinghouse/vendor or UnitedHealthcare at
888-804-0663 or [email protected].
By a scheduled end date of January 2014, all pharmacy
benefit services for our commercial members which are
currently handled by Medco will be transferred to OptumRx.
Consolidating our pharmacy
services through OptumRx will help
us to better partner with you and
our members to improve health
outcomes and better manage total
health care costs.
Prescription drug lists, benefit plan
designs, specialty pharmacy and
clinical programs will continue to
be managed by UnitedHealthcare
and members will continue to have
access to more than 64,000 retail
network pharmacies. This change
will not require any action on your
part or that of your patients and
we will automatically transition
information to OptumRx related to
the these essential elements.
You and Your Patients
Most existing mail service
prescriptions will transfer to
OptumRx as well. Prescriptions for
certain medications, like painkillers
and expired prescriptions, will not
transfer, and your patient will receive
a letter from UnitedHealthcare
instructing them to contact your
office for a new prescription.
Once your patients transition
to OptumRx, you’ll find that the
Online Prior Authorization tool at
Continued >
42
< Continued
UnitedHealthCareOnline.com is easy to use.
The majority of online prior authorizations are approved
in real time, and an auto-population feature provides
95 percent of a member’s information. The OptumRx
Prior Authorization team is also available by phone at
800-711-4555.
benefits, the transition has been occurring in stages
with completion expected by the end of January 2014.
We’ve provided the schedule below (see chart, subject
to change), but you may also want to ask patients
to present their new ID card, which will contain the
updated information.
In addition to UnitedHealthcare’s commercial
members, this change will apply to prior authorizations
for Oxford, Medica, Harvard Pilgrim, River Valley
and Neighborhood Health Plan. The Online Prior
Authorization tool is available for these plans through
OptumRx.com. For members of Health Plan of Nevada
and Sierra Health & Life, please continue to use the
current prior authorization process.
Transition has been completed for:
•
UnitedHealthcare employees and select
UnitedHealthcare commercial and Harvard
Pilgrim members;
•
UnitedHealthcare commercial, Medica and
Harvard Pilgrim members in the West and
Northeast regions;
If you e-prescribe through Sure Scripts, the NCPDP ID
for OptumRx is #0556540.
•
Harvard Pilgrim members in the Central
region; and
Timing Considerations
•
Harvard Pilgrim national account customers
across all regions.
To ensure that members experience seamless service
and access to the full range of covered pharmacy
Continued >
43
< Continued
Transactions for the following are expected to be completed by
end of January 2014:
Date
Region
Plans
•
Sept. 1, 2013 - UnitedHealthcare commercial, Medica and
Harvard Pilgrim members in the Southeast region.
Jan. 1, 2013
•
Oct. 1, 2013 - Oxford, Sierra, River Valley and Neighborhood Health
Plan members in all regions.
UnitedHealthcare
Employees and
Select Clients
UnitedHealthcare
Commercial,
Harvard Pilgrim
Apr. 1, 2013
West Region and
Northeast Region
UnitedHealthcare
Commercial, Medica,
Harvard Pilgrim
June 1, 2013
Central Region
UnitedHealthcare
Commercial, Medica,
Harvard Pilgrim
July 1, 2013
National Account
Clients Across
all Regions
UnitedHealthcare
Commercial, Medica,
Harvard Pilgrim
Sept. 1, 2013
Southeast Region
UnitedHealthcare
Commercial, Medica,
Harvard Pilgrim
Oct. 1, 2013
All Regions
Oxford, Sierra, River Valley,
Neighborhood Health Plan
Jan. 1, 2014
All Regions
UnitedHealth One
•
Jan. 1, 2014 - UnitedHealth One members in all regions.
•
June 1, 2013 Central region UnitedHealthcare commercial, Medica,
Harvard Pilgrim.
•
44
July 1, 2013 Network Bulletin: September 2013 - Volume 57
Synagis® (palivizumab) Procurement Process
for the 2013-14 RSV Season
Please remember that Synagis must be obtained from OptumRx Specialty Pharmacy, our
contracted specialty pharmacy vendor for Synagis,* as described in the UnitedHealthcare
Administrative Guide protocol for contracted providers.
This is the same procedure required during the
2012-13 RSV season. OptumRx’s staff follows
UnitedHealthcare’s drug policy criteria for Synagis and
works directly with the Clinical Coverage Review unit
to determine whether members meet clinical eligibility
criteria for Synagis. Synagis should be obtained by
using the UnitedHealthcare Specialty Pharmacy
Services Enrollment Form for RSV.
UnitedHealthcare’s Synagis policy reflects current
recommendations from the American Academy of
Pediatrics and its Committee on Infectious Diseases
(COID). A copy of our drug policy is available at
UnitedHealthcareOnline.com >Tools & Resources >
Policies & Protocols >Medical & Drug Policies and
Coverage Determination Guidelines > Synagis Policy.
Enrollment forms are available at
UnitedHealthcareOnline.com > Tools & Resources >
Pharmacy Resources and may be submitted directly
to OptumRx by fax at 800-853-3844. UnitedHealthcare
does not participate in MedImmune’s sponsored
RSV Connection™ Program. We have contracted
with OptumRx to work with physicians to collect our
members’ clinical and eligibility information, and to
provide a timely review of Synagis requests.
Synagis requests for our members must be made
through OptumRx Specialty Pharmacy for the 2013-14
RSV season. The most recently available RSV activity
reports from state or local health departments or the
Centers for Disease Control and Prevention)* should be
submitted along with the enrollment form for requests
Continued >
45
Synagis® (palivizumab) Procurement Process
for the 2013-14 RSV Season
< Continued
that include doses to be administered prior to
Nov. 1, 2013 or after March 31, 2014.
doses) which should provide coverage during the peak
of the season, when prophylaxis is most effective.**
In most of North America, peak RSV activity
typically occurs between Nov. and March.
As stated in our drug policy, palivizumab is
unproven when administered:
Benefit coverage is not available to UnitedHealthcare
members for health services that we conclude are
unproven. The National Respiratory and Enteric
Virus Surveillance System (NREVSS) defines RSV
national and regional season onset as the first of two
consecutive weeks during which the mean percentage
of specimens testing positive for RSV antigen is greater
or equal to 10 percent and offset as the last of two
consecutive weeks during which the mean percentage
of positive specimens is greater or equal to 10 percent.
•
Out of season;
•
In doses greater than needed to provide
protection in season;
•
In excess of five doses per single RSV season;
•
To persons other than those defined as high risk.
Children who may qualify for the entire RSV season –
including infants and children with chronic lung disease
of prematurity or congenital heart disease or pre-term
infants born before 32 weeks gestation - should receive
palivizumab only during the five months following the
onset of RSV season in their region (maximum of five
46
* This does not apply to the State of New York (Empire Plan).
Additional Information: http://www.cdc.gov/rsv/index.html
Reference: *. Centers for Disease Control and Prevention. Respiratory
Syncytial Virus Activity — United States, July 2011–January 2013. MMWR.
March 1, 2013 / 62(08);141-144.
**American Academy of Pediatrics. Respiratory syncytial virus. In: Red Book:
2012 Report of the Committee on Infectious Diseases, 29th, Pickering LK. (Ed),
American Academy of Pediatrics, Elk Grove Village, IL 2012.
Clinical Updates
Effective Dec. 1: Online Clinical
Submissions to be Required
Optum™ Physical Health will require that all
clinical submissions (Patient Summary Form,
PSF-750) be submitted via the Optum website
at www.myoptumhealthphysicalhealth.com
effective Dec. 1, 2013.
Participating providers will be notified 90 days prior to the
online submission requirements effective date.
PSF-750 forms received by fax will not be accepted and may
result in delayed or denied payment. Contact Optum Provider
Services at 800-985-3293 or 877-369-7564 with questions or to
obtain your Provider ID and password.
47
Clinical Update
Clinical Practice Guidelines
UnitedHealthcare uses
evidence-based clinical
guidelines from nationally
recognized sources to
guide our quality and health
management programs.
The following clinical practice
guidelines are available at
under Tools & Resources >
Policies, Protocols and
Guides > Medical & Drug
Policies and Coverage
Determination Guidelines >
Clinical Guidelines.
Topic
Organization
Acute Myocardial Infarction with ST Elevation
American College of Cardiology Foundation/American Heart
Acute Myocardial Infarction without ST Elevation
American College of Cardiology Foundation/American Heart
Asthma
National Heart, Lung and Blood Institute
Attention Deficit Hyperactivity Disorder (ADHD)
American Academy of Child and Adolescent Psychiatry
Bipolar Disorder: Adults
American Psychiatric Association
Bipolar Disorder: Children & Adolescents
American Academy of Child and Adolescent Psychiatry
Cardiovascular Disease: Prevention in Women
American Heart Association
Cardiovascular Disease: Secondary Prevention and Risk
Reduction Therapy for Patients with Coronary and Other
Atherosclerotic Vascular Disease
American College of Cardiology/American Heart Association
Cholesterol Management
Chronic Obstructive Lung Disease
Global Initiative for Chronic Obstructive Lung Disease (GOLD)
Continued >
48
< Continued
Clinical Update
Clinical Practice
Guidelines
Topic
Organization
Chronic Stable Angina
Depression/ Major Depressive Disorder
American Psychiatric Association
Diabetes
American Diabetes Association
Heart Failure
Hemophilia and von Willebrand Disease
World Federation of Hemophilia and National Heart, Lung & Blood
Human Immuno-deficiency Virus (HIV)
HIV Medicine Association of the Infectious Diseases Society of America
Hyperbili-rubinemia in Newborns
American Academy of Pediatrics
Hypertension
Preventive Services
Agency for Healthcare Research and Quality
Schizophrenia
American Psychiatric Association/PsychiatryOnline Guideline Watch
Sickle Cell Disease
Spinal Stenosis
North American Spine Society
Substance Use Disorders
American Psychiatric Association/PsychiatryOnline
This information is for general reference and not intended to address every aspect of a clinical situation. Clinical discretion should be used
to interpret and apply this information to individual patients. If you do not have internet access and would like to obtain copies of a guideline,
please contact our National Quality Management and Performance Team at 954-447-8818.
49
Clinical Update
Coordination of Care Between
PCPs and Specialists
Primary care physicians (PCPs) and specialists share responsibility for communicating
essential patient information regarding consultations and referrals. When open
communications does not occur consistently, it can affect providers’ ability to provide
high quality care.
According to a recent study*, there is a difference
of opinion among providers regarding the frequency
of information provided and received. Though more
than two-thirds of PCPs said they send specialists
notification of a patient’s history and the reason for
the consultation all or most of the time, only a third of
specialists said they routinely receive such information,
according to the study.
Meanwhile, more than 80 percent of specialists say
they send consultation results to the referring
physician all or most of the time, but only 60 percent
of PCPs say they get that information.
Relevant information from the PCPs includes Patient
history and Diagnostic tests and results and the reason
for the consultation.
The specialist is responsible for communicating the
consultation results and ongoing recommendations
and treatment plans.
Information exchange between providers should be
timely, relevant and accurate to facilitate ongoing
patient management. The partnership between PCPs
and specialists is based on the consistent exchange
of clinical information and this communication is a key
factor in providing quality patient care.
* Literature reference: Arch Intern Med. 2011 Jan Vol. 171 (1):56-65
.
50
Neighborhood Health Partnership
Prior Authorization Requirement –
Outpatient Injectable Chemotherapy
Effective in the fourth quarter of 2013, the process
to submit chemotherapy prior authorizations
for members insured by Neighborhood Health
Partnership will change. Details on how to obtain
prior authorization will be included in a future Network
Bulletin as well as letters to impacted providers.
51
Oxford Medical and Administrative
Policy Updates
For complete details
on the new and/or
revised policies listed in
the table below, refer to
the monthly Policy
Update Bulletin at
OxfordHealth.com
> Providers > Tools &
Resources > Practical
Resources > Medical and
Administrative Policies >
Policy Update Bulletin.
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Custodial and Skilled Care Services
Administrative Policy
Aug. 1, 2013
July 2013
Implanted Electrical Stimulator for Spinal Cord
Clinical Policy
Aug. 1, 2013
July 2013
Interim New Product Coverage Criteria
Clinical Policy
Oct. 1, 2013
Sept. 2013
17-Alpha-Hydroxyprogesterone Caproate
(Makena™ and 17P)
Clinical Policy
Aug. 1, 2013
July 2013
Abnormal Uterine Bleeding and Uterine Fibroids
Clinical Policy
Aug. 1, 2013
July 2013
Abortions (Therapeutic and Elective)
Clinical Policy
Aug. 1, 2013
July 2013
Ampyra™ (Dalfampridine)
Clinical Policy
Aug. 15, 2013
July 2013
Aug. 2013
NEW
UPDATED/REVISED
Continued >
52
< Continued
UnitedHealthcare
Affiliates
Oxford Medical
and Administrative
Policy Updates
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Bilateral Procedures Policy
Jul. 1, 2013
Aug. 2013
Cardiology Procedures for CareCore
National Arrangement
Clinical Policy
Oct. 1, 2013
July 2013
Aug. 2013
Sept. 2013
Cardiology Procedures Requiring Precertification
Clinical Policy
Oct. 1, 2013
July 2013
Aug. 2013
Sept. 2013
Cayston (Aztreonam for Inhalation Solution)
Clinical Policy
Aug. 15, 2013
July 2013
Aug. 2013
Diabetes Supply Coverage
Clinical Policy
Sept. 1, 2013
Aug. 2013
Diabetic Insulins
Clinical Policy
Aug. 1, 2013
July 2013
Drug Coverage Criteria - New and Therapeutic
Equivalent Medications
Clinical Policy
Aug. 15, 2013
July 2013
Sept. 1, 2013
Aug. 2013
Aug. 1, 2013
July 2013
Aug. 15, 2013
July 2013
Aug. 2013
Sept. 1, 2013
Aug. 2013
Oct. 1, 2013
Sept. 2013
Drug Coverage Guidelines
Clinical Policy
Continued >
53
< Continued
UnitedHealthcare
Affiliates
Oxford Medical
and Administrative
Policy Updates
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Early Intervention Program/Birth to Three
Clinical Policy
Aug. 1, 2013
July 2013
Epidural Steroid and Facet Injections for
Spinal Pain
Clinical Policy
Aug. 1, 2013
Aug. 2013
Gastrointestinal Motility Disorders, Diagnosis
and Treatment
Clinical Policy
Sept. 1, 2013
Aug. 2013
Global Days
Jul. 1, 2013
Aug. 2013
Home Health Care
Clinical Policy
Aug. 1, 2013
July 2013
Hospice Care
Clinical Policy
Aug. 1, 2013
July 2013
Human Immunodeficiency Virus (HIV)
Tropism Testing
Clinical Policy
Sept. 1, 2013
Aug. 2013
Increased Procedural Services
Aug. 1, 2013
July 2013
In-Network Exceptions for Breast Reconstruction
Surgery Following Mastectomy
Clinical Policy
Aug. 1, 2013
July 2013
Inpatient Maternity Stay and Subsequent
Home Nursing
Aug. 1, 2013
July 2013
Continued >
54
< Continued
UnitedHealthcare
Affiliates
Oxford Medical
and Administrative
Policy Updates
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Interferon Alphas
Clinical Policy
Aug. 15, 2013
July 2013
Aug. 2013
Lupron-Depot (Leuprolide Acetate)
Clinical Policy
Aug. 1, 2013
July 2013
Maximum Dosage Policy
Clinical Policy
Oct. 1, 2013
Aug. 2013
Sept. 2013
Moderate Sedation Policy
Sept. 1, 2013
Aug. 2013
Modifier Reference Policy
Aug. 1, 2013
July 2013
Obstetrical Policy
Sept. 1, 2013
Aug. 2013
Oxford's Outpatient Imaging Self-Referral Policy
Clinical Policy
Sept. 1, 2013
Aug. 2013
Precertification Exemptions for Outpatient Services
Aug. 1, 2013
July 2013
Preterm Labor: Identification and Treatment
Clinical Policy
Aug. 1, 2013
July 2013
Preventive Care
Clinical Policy
Aug. 1, 2013
July 2013
Oct. 1, 2013
Aug. 2013
Sept. 2013
Continued >
55
< Continued
UnitedHealthcare
Affiliates
Oxford Medical
and Administrative
Policy Updates
Policy Title
Policy Type
Effective
Date
Policy Update
Bulletin
Clinical Policy
Aug. 1, 2013
July 2013
Psychological and Neuropsychological Testing
Clinical Policy
Aug. 1, 2013
July 2013
Sodium Hyaluronate
Clinical Policy
Aug. 1, 2013
July 2013
Standing Systems
Clinical Policy
Aug. 1, 2013
July 2013
Time Span Codes Policy
Sept. 1, 2013
Aug. 2013
Transcatheter Heart Valve Procedures
Clinical Policy
Aug. 1, 2013
July 2013
Tysabri (Natalizumab)
Clinical Policy
Aug. 1, 2013
July 2013
Utilization Management Appeal Process
and Timeframes for Connecticut Plans
Jun. 11, 2013
July 2013
Vaccines
Clinical Policy
Sept. 1, 2013
Aug. 2013
Vision Services
Clinical Policy
Sept. 1, 2013
Aug. 2013
Xolair (Omalizumab)
Clinical Policy
Aug. 1, 2013
July 2013
Note: The appearance of a service or procedure on this list does not imply that Oxford provides coverage for the service or procedure. In the event
of an inconsistency or conflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy will prevail.
Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc.
Oxford insurance products are underwritten by Oxford Health Insurance, Inc.
56
SignatureValue™ Medical Management
Guideline Updates
on the new and/or
revised policies listed
in the table below,
refer to the monthly
SignatureValue™
Medical Management
Guidelines Update
Bulletin at
UHCWest.com >
Provider Log In >
Library > Resource
Center > Guidelines &
Interpretation Manuals.
Policy Title
Effective Date
Policy Update Bulletin
July 1, 2013
July 2013
Abnormal Uterine Bleeding and Uterine Fibroids
July 1, 2013
July 2013
Chemotherapy Observation or Inpatient Hospitalization
Sept. 1, 2013
Aug. 2013
Corneal Hysteresis and Intraocular Pressure Measurement
July 1, 2013
July 2013
Diabetes Management Guidelines: Clinical Practice Guideline
July 1, 2013
July 2013
Epidural Steroid and Facet Injections for Spinal Pain
July 1, 2013
July 2013
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Sept. 1, 2013
Aug. 2013
Hepatitis Screening
July 1, 2013
July 2013
High Frequency Chest Wall Compression Devices
Sept. 1, 2013
Aug. 2013
NEW
Implanted Electrical Stimulator for Spinal Cords
UPDATED/REVISED
Continued >
57
< Continued
UnitedHealthcare
Affiliates
SignatureValue™
Medical Management
Guideline Updates
Policy Title
Effective Date
Human Immunodeficiency Virus (HIV) Tropism Testing
Sept. 1, 2013
Aug. 2013
Omnibus Codes
July 1, 2013
July 2013
Sept. 1, 2013
Aug. 2013
Panniculectomy and Body Contouring Procedures
Oct. 1, 2013
Sept. 2013
Pectus Deformity Repair
Oct. 1, 2013
Sept. 2013
Preterm Labor: Identification and Treatment
July 1, 2013
July 2013
Sept. 1, 2013
Aug. 2013
Sept. 1, 2013
Aug.2013
Rhinoplasty, Septoplasty, and Repair of Vestibular Stenosis
July 1, 2013
July 2013
Sodium Hyaluronate
July 1, 2013
July 2013
Surgical and Ablative Procedures for Venous Insufficiency and
Varicose Veins
Oct. 1, 2013
Aug. 2013
Sept. 2013
Transcatheter Heart Value Procedures
July 1, 2013
July 2013
Aug. 1, 2013
Aug. 2013
REPLACED/RETIRED
Transthoracic Echocardiography
Note: The appearance of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency or conflict between the information provided in this Bulletin and the posted policy, the provisions of the posted policy will prevail.
58
SignatureValue™ Benefit Interpretation
Policy Updates
on the revised policy
listed below, refer to the
monthly SignatureValue™
Benefit Interpretation
Policy Update Bulletin at
UHCWest.com
> Provider Log In >
Library > Resource
Center > Guidelines &
Interpretation Manuals.
59
Policy Title
Applicable State(s)
Effective
Date
All (California, Oklahoma,
Oregon, Texas and Washington)
July 1, 2013
July 2013
UPDATED/REVISED
Durable Medical Equipment (DME),
Prosthetics, Corrective Appliances/Orthotics
(Non-Foot Orthotics) and Medical Supplies
Note: The appearance of a service or procedure on this list does not imply that coverage is provided for the service or procedure. In the event of an
inconsistency or conflict between the information provided in this bulletin and the posted policy, the provisions of the posted policy will prevail.
UnitedHealthcare of the River Valley
Preauthorization List and Policy Updates for
Commercial and hawk-i Members Only
on the new and/or
revised policies and
guidelines listed below,
refer to the monthly
Policy Update Bulletin at
UHCRiverValley.com
> Providers > Coverage
Policy Library.
These updates apply to
UnitedHealthcare of the
River Valley commercial
and hawk-i plan
membership only. They
do not apply to members
enrolled in a River Valley
Ohio product or South
Carolina product.
60
Policy Title
Effective Date
17-Alpha-Hydroxyprogesterone Caproate (Makena™ and 17P)
Oct. 1, 2013
Sept. 2013
Benlysta (Belimumab)
Oct. 1, 2013
Sept. 2013
Epidural Steroid and Facet Injections for Spinal Pain
Oct. 1, 2013
Sept. 2013
Gastrointestinal Motility Disorders, Diagnosis and Treatment
Nov. 1, 2013
Sept. 2013
Hereditary Angioedema (HAE), Treatment and Prophylaxis
Oct. 1, 2013
Sept. 2013
Home Traction Therapy
Nov. 1, 2013
Sept. 2013
Human Immunodeficiency Virus (HIV) Tropism Testing
Oct. 1, 2013
Sept. 2013
Laser Therapy for Cutaneous Vascular Lesions and Pilonidal Disease
Oct. 1, 2013
Sept. 2013
UPDATED/REVISED
Continued >
< Continued
UnitedHealthcare
Affiliates
UnitedHealthcare of
the River Valley
Preauthorization List
and Policy Updates
for Commercial and
hawk-i Members Only
Policy Title
Effective Date
Manipulative Therapy
Oct. 1, 2013
Sept. 2013
Oct. 1, 2013
Sept. 2013
Nov. 1, 2013
Sept. 2013
Standing Systems
Oct. 1, 2013
Sept. 2013
Tysabri (Natalizumab)
Oct. 1, 2013
Sept. 2013
Vaccines
Oct. 1, 2013
Sept. 2013
Xolair (Omalizumab)
Oct. 1, 2013
Sept. 2013
Note: The appearance of a service or procedure on this list does not imply that UnitedHealthcare provides coverage for the service or
procedure. In the event of an inconsistency or conflict between the information provided in this bulletin and the posted policy, the provisions
of the posted policy will prevail.
61
Odds & Ends
Optum Bank offers financing to health care providers who are
investing in new technology or equipment, expanding through
real estate purchase or renovation, or need working capital.
Optum Bank provides: Easy loan process
Valuable consultation
Get direct access to a loan officer.
Closings can be arranged in providers’
offices. Find a loan application at
optumbank.com.
Financing specialists follow up
30 days after a loan closing and do
annual reviews to monitor satisfaction.
No-obligation consultations
with financing and other experts
are available to providers. The
bank also offers optional $200 to
$500 contributions to local
health-related charities as a
co-sponsor with providers.
Fast follow-up
Loan officers call providers back
the same day they submit
applications. The bank offers
personalized service, face-to-face
meetings and credit decisions
based on providers’ schedules.
Continued >
62
Odds and Ends
< Continued
The bank’s lending services are particularly suited to small
and mid-size providers.
Optum Bank does not ask providers
to make changes in their other banking relationships.
For more information:
Contact Nicholas Berger, senior loan officer,
at [email protected] or
801-963-7230. Optum Bank is part of Optum,
a division of UnitedHealth Group.
63
Odds and Ends
UnitedHealthcare Adoption of Administrative Simplification
Operating Rules for Electronic EFT and ERA
UnitedHealthcare is
implementing the following
enhanced system and process
changes effective Jan. 1,
2014, for CAQH/CORE
Phase III Certification in
compliance with the Operating
Rules for Electronic Funds
Transfer (EFT) and Electronic
Remittance Advice (ERA)
required by the Department of
Health and Human Services
in compliance with the Health
Insurance Portability and
Accountability Act (HIPAA).
For more information visit
the Committee on Operating
.Rules for Information
Exchange (CORE) website at
http://www.caqh.org/ORMandate_EFT.php.
64
Rule #
Rule Name
High-Level Requirements
350
Health Care Claim Payment/Advice (835)
Infrastructure Rule
• Specifies use of CAQH CORE Master Companion Guide Template
• Requires entities to support Phase II CAQH CORE Connectivity Rule
• Defines a dual-delivery (paper/electronic) to facilitate providers transitioning
to electronic remits
360
Uniform Use of Claim Adjustment Reason
Codes (CARCs) and Remittance Advice
Remark Codes (RARCs): 835 Rule
• Identifies a minimum set of four CAQH CORE-defined business scenarios
with a maximum set of CAQH CORE- required code combinations that can
be applied to convey details of the claim denial or payment to the provider
370
EFT & ERA Re-association (CCD+/835) Rule
• Addresses provider receipt of the CAQH CORE-required Minimum
Automated Clearing House (ACH) CCD+ Data Elements required
for re-association
• Addresses elapsed time between the sending of the v5010 835 and
the CCD+ transactions
• Requirements for resolving late/missing EFT and ERA transactions
• Recognition of the role of NACHA Operating Rules for financial institutions
380
EFT Enrollment Data Rule
• Identifies a maximum set of standard data elements for EFT enrollment
• Outlines a “straw man” template for paper and electronic collection
of data elements
• Requires health plan to offer electronic EFT enrollment
382
ERA Enrollment Data Rule
• Identifies a maximum set of standard data elements for ERA enrollment
• Outlines a “straw man” template for paper and electronic collection
of data elements
• Requires health plan to offer electronic ERA enrollment
Odds and Ends
EPS Data Packages for Faster
Downloads Now Available
If you use Electronic Payments and Statements (EPS) to retrieve claims remittance
information, now you can make that process quicker with new “data bundle” downloads.
Log into EPS at optumhealthfinancial.com, and you can
request ZIP files that will bundle data from one or more
payers for the date or date range you select.
Up to 13 months of 835s and EPRAs are available.
Limited MEOB data is available, but those files will build
over time until 13 months of back data is available, too.
You can choose which data to include, such as:
835 remittance information, electronic proprietary
remittance advice (EPRA) and/or multiple explanations
of benefits (MEOBs). Most data requests will be ready
for download within one to two hours. You will receive
an email notifying you when your data file is available
on the EPS website so you can log in and retrieve it.
The data packages are available by logging into EPS
at optumhealthfinancial.com. They are not available if
you log into EPS through UnitedHealthcareOnline.com.
Data files will be stored on the website for seven days
and then deleted. If you don’t download files within the
time allotted, you can return to the website and request
a new download.
65
In addition, we now will send just one email per
day to notify you that one or more claims payments
have been deposited into your account, rather than
multiple notifications.
More information on EPS enhancements can
be found in the “News” section on the EPS
“Bulletin Board.”

net work bulletin Network Bulletin: September 2013 - Volume 57

Transcription

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