March 2013 - Volume 54
An important message from UnitedHealthcare to health care professionals and facilities
Focus on Star
Reach for the Stars
UnitedHealthcare is committed to offering programs and
services that support your efforts to provide the highest
quality care. Toward that goal, we would like to share best
practices for identifying care opportunities and improving
Centers for Medicare & Medicaid Services (CMS) Star
Ratings across our provider network.
Here are some best practices for scheduling patients for their
recommended preventive care:
• Use View360 to access a patient’s history to identify what
recommended screenings, treatments or exams are needed
2013 UnitedHealthcare
Administrative Guide Available
The new UnitedHealthcare Physician, Health
Care Professional, Facility and Ancillary Provider
2013 Administrative Guide is effective April 1,
2013 for currently participating physicians, health
care professionals, facilities and ancillary providers.
For new participants in our provider network on
or after January 1, 2013, the guide is effective
immediately. Please refer to the January 2013
Network Bulletin for details on changes to the
2013 guide.
• Call patients and inform them of their outstanding
preventive screenings, treatments or exams
• Schedule an appointment over the phone
• Document outstanding preventative screenings, treatments
or exams in the patient’s chart with every visit
• Educate patient on what are the recommended screenings,
treatments and exams
Visit cms.gov for a list of recommended preventive services.
Working together, we can help our Medicare members get
the most from their benefits. Please share your best practice
tips by emailing us at networkbulletin@uhc.com.
Revision to: Changes to the Outpatient Radiology
Notification Program and Cardiology Notification
Program article on pg. 12 to include “required” at the
end of the 3rd bullet (March 5, 2013).
For more information call 877.842.3210 or visit UnitedHealthcareOnline.com
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
Front & Center
• Focus on Star - Reach for the Stars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
• 2013 UnitedHealthcare Administrative Guide Available . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
• Provisor - Caring for your UnitedHealthcare Patients Just Got Easier. . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
• National Doctors’ Day is March 30, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
• UnitedHealth Premium Results Now Available to Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
UnitedHealthcare Commercial
• UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guideline and Utilization
Review Guideline Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
• Reminder of Advance Notification List Updates to the 2013 UnitedHealthcare Administrative Guide
for UnitedHealthcare Commercial Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
• Changes to the Outpatient Radiology Notification Program and Cardiology Notification Program for
Commercial Members, Effective July 1, 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
UnitedHealthcare Reimbursement Policy
• Revision to Speech Therapy Policy - Physical Medicine and Rehabilitation . . . . . . . . . . . . . . . . . . . . . . 15
• Revision to Increased Procedural Services Policy - Documentation Requirements for Modifier 22 . . . . 15
• Telemedicine Policy - Language Added Relating to Authorized Provider Specialties . . . . . . . . . . . . . . . . . 15
• Revision to Professional/Technical Component Policy for Selected Radiology Services
Reported in a POS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
UnitedHealthcare Medicare Solutions
• Submit Medicare Part D Claims to OptumRX for Prompt Processing . . . . . . . . . . . . . . . . . . . . . . . . . . 17
• UnitedHealthcare Medicare Solutions Reimbursement Policies Available . . . . . . . . . . . . . . . . . . . . . . . . 17
• UnitedHealthcare Medicare Advantage Coverage Summary Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
• Rights and Responsibilities for Medicare Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
UnitedHealthcare Community Plan
• Prior Authorization Review Required for Selected Injectable Medications for UnitedHealthcare
Community Plan Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
• UnitedHealthcare Community Plan to Use National Comprehensive Cancer
Network Compendium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
UnitedHealthcare Military & Veterans
• TRICARE West Region Website Now Active . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
UnitedHealthcare Pharmacy
• Specialty Medication Prescriptions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
• UnitedHealthcare Pharmacy Physician Prescription Drug List Online . . . . . . . . . . . . . . . . . . . . . . . . . . 22
• Important Update in Preauthorization and Acquisition of Hyaluronic Acid Products. . . . . . . . . . . . . . . 23
• New Fax Line to Assist with Expedited/Urgent Pharmacy Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
• Prior Authorization Required for H.P. Acthar Gel and Immune Globulin Medications
for UnitedHealthcare Commercial. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
• Update: Alternatives Added for Jan. 1, 2013 Pharmacy Benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
(continued on next page)
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For more information, visit UnitedHealthcareOnline.com
Table of Contents
(continued from previous page)
Doing Business Better
• Keeping Your Information Up-to-date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
• Updates to myHealthcare Cost Estimator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
• Reminder to Use Network Laboratories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
• Credentialing Plan Changes Effective April 1, 2013. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
• Advance Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
• Reminder: Important Change to DME Provider Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
UnitedHealthcare Claims, Billing and Coding
• Radiology Program Procedure Code Changes - Effective Jan.1, 2013 . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
• Appropriate Modifiers Required for DME Billing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
• Chemotherapy Drug Review on Hospital Claims . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
• Improved Process for Claim Reconsideration Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
• National Comprehensive Cancer Network Drug Compendium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
• Use of Avastin as Maintenance Therapy for Non-Small Cell Lung Cancer . . . . . . . . . . . . . . . . . . . . . . 31
• Transcutaneous Electrical Nerve Stimulation for Chronic Low Back Pain Medicare Solutions
Policy Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
• Mandatory Inpatient CPT Coding Must Be Accompanied by Mandatory Written Inpatient Order . . . 31
• Accurate Billing Improves Office Efficiency and Dual SNP Member Satisfaction . . . . . . . . . . . . . . . . 32
• Proton Beam Radiation Therapy Prior Authorization
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
UnitedHealthcare Clinical
• Patient Education Materials Available for Behavioral and Substance Abuse Issues . . . . . . . . . . . . . . . . . 33
UnitedHealthcare Affiliates
• Reminder Regarding Milliman Care Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
• New Pre-certification Requirements for Non-preferred Diabetes Medications and
Test Strips for Oxford Members Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
• Additional Precertification Codes for Neighborhood Health Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
• UnitedHealthcare of the River Valley Preauthorization List and Policy Updates . . . . . . . . . . . . . . . . . . . 35
• Oxford Medical and Administrative Policy Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
• SignatureValue Medical Management Guideline Updates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
• SignatureValue Benefit Interpretation Policy Updates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
• UnitedHealthcare West Requires Prior Authorization for Bevacizumab . . . . . . . . . . . . . . . . . . . . . . . . . 48
Odds and Ends
• Enhancements to UnitedHealthcareOnline.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
• Manage Receivables More Efficiently with Direct Deposit and Online Explanation of Benefits . . . . . . 48
• UnitedHealthcare’s 835 File Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
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For more information, visit UnitedHealthcareOnline.com
Front & Center
Provisor - Caring for Your
UnitedHealthcare Patients
Just Got Easier
UnitedHealth Premium Results
Now Available to Public
All UnitedHealth Premium physician designations
are now published online on our member websites
such as myuhc.com.
Provisor - Coming March 1, 2013
Do you need information about your patients?
It’s available at your fingertips through our
iPhone®/iPad® App, where you can access the
following and more:
Notifications of new UnitedHealthcare Premium
designations for quality and cost efficiency were
sent by mail to physicians in October 2012. The
physicians’ letters included instructions on
how to access their full suite of UnitedHealth
Premium assessment reports online at
UnitedHealthcareOnline.com. Physicians
may also submit reconsideration requests online
through this site.
• Our current base formularies (prescription
drug lists)
• Members’ personal health records
• Drug Reference information
Log on to UnitedHealthcareOnline.com to access
information about Provisor under
Tools>Resources>Health Information
Technology.
Most physician designations were posted on Dec. 26,
2012. The publication date for physicians in
Connecticut, New Jersey and New York was
extended to Jan. 26, 2013 to provide additional time
for those practices impacted by Hurricane Sandy.
National Doctors’ Day is March 30
For questions about the program:
On 2013 National Doctors’ Day, we honor you.
And every day, we appreciate you. Thank you for
helping our members live healthier lives.
• Visit UnitedHealthcareOnline.com >
UnitedHealth Premium
From all of us at UnitedHealthcare Provider
Relations
• Email UnitedHealthcareOnline.com >
UnitedHealth Premium > Contact Premium
Program
• Or call 866-270-5588
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
UnitedHealthcare Medical Policy, Drug Policy, Coverage Determination Guidelines
and Utilization Review Guidelines Updates
The following table outlines the Medical Policies, Drug Policies, Coverage Determination Guidelines
(CDGs) and/or Utilization Review Guidelines (URGs) recently adopted or revised by UnitedHealthcare.
A detailed summary of the updates is available on UnitedHealthcareOnline.com through the monthly
Medical Policy Update Bulletin.
The bulletin is published on the first day of every month at UnitedHealthcareOnline.com > Tools &
Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage
Determination Guidelines > Medical Policy Update Bulletin.
Policy Title
Medical Policy
Update Bulletin
Policy Type
Effective Date
Breast Pumps
URG
Apr. 1, 2013
January 2013
February 2013
March 2013
Electrical and Ultrasound Bone Growth Stimulators
Medical Policy
Apr. 1, 2013
January 2013
February 2013
March 2013
Private Duty Nursing
CDG
May 1, 2013
February 2013
March 2013
Repository Corticotropin Injection (H.P. Acthar Gel)
Drug Policy
Apr. 1, 2013
January 2013
February 2013
March 2013
Abnormal Uterine Bleeding and Uterine Fibroids
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Apheresis
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Bariatric Surgery
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Blepharoplasty, Blepharoptosis and Brow Ptosis Repair
CDG
Apr. 1, 2013
February 2013
March 2013
Complementary and Alternative Medicine
CDG
Mar. 1, 2013
February 2013
Continuous Glucose Monitoring and Insulin Delivery for
Managing Diabetes
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Cosmetic and Reconstructive Procedures
CDG
Apr. 1, 2013
February 2013
March 2013
NEW
UPDATED/REVISED
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Policy Title
Medical Policy
Update Bulletin
Policy Type
Effective Date
Custodial and Skilled Care Services
CDG
Apr. 1, 2013
February 2013
March 2013
Deep Brain Stimulation
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Electrical Stimulation for the Treatment of Pain and
Muscle Rehabilitation
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Gastrointestinal Motility Disorders, Diagnosis and
Treatment
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Glaucoma Surgical Treatment
Medical Policy
Apr. 1, 2013
February 2013
March 2013
High Frequency Chest Wall Compression Devices
Medical Policy
Apr. 1, 2013
February 2013
March 2013
High Ligation and Endomechanical Ablation for Varicose
Veins
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Immune Globulin
Drug Policy
Apr. 1, 2013
January 2013
February 2013
March 2013
Implantable Beta-Emitting Microspheres for Treatment of Medical Policy
Malignant Tumors
Apr. 1, 2013
February 2013
March 2013
Infertility Diagnosis and Treatment
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Intensity-Modulated Radiation Therapy
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Magnetoencephalography and Magnetic Source Imaging Medical Policy
for Specific Neurological Applications
Apr. 1, 2013
February 2013
March 2013
Mandibular Disorders
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Manipulation Under Anesthesia
Medical Policy
Mar. 1, 2013
February 2013
Mechanical Stretching and CPM Devices
Medical Policy
Apr. 1, 2013
February 2013
March 2013
UPDATED/REVISED (continued)
(continued on next page)
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Policy Title
Medical Policy
Update Bulletin
Policy Type
Effective Date
Non-Surgical Treatment of Obstructive Sleep Apnea
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Omnibus Codes
Medical Policy
Feb. 1, 2013
January 2013
Physical Medicine and Rehabilitation Services
CDG
Mar. 1, 2013
February 2013
Plagiocephaly and Craniosynostosis
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Preventive Care Services
CDG
Apr. 1, 2013
February 2013
March 2013
Prosthetic Devices and Wigs
CDG
Apr. 1, 2013
February 2013
March 2013
Proton Beam Radiation Therapy
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Radiofrequency Therapy and Tibial Nerve Stimulation for
Urinary Disorders
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Rhinoplasty, Septoplasty, and Repair of Vestibular
Stenosis
CDG
Apr. 1, 2013
February 2013
March 2013
Specialized, Microprocessor or Myoelectric Limbs
CDG
Apr. 1, 2013
February 2013
March 2013
Speech Language Pathology Services
CDG
Apr. 1, 2013
February 2013
March 2013
Surgical Treatment for Spine Pain
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Surgical Treatment of Obstructive Sleep Apnea
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Total Artificial Heart
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Transcatheter Heart Valve Procedures
Medical Policy
Apr. 1, 2013
February 2013
March 2013
Vagus Nerve Stimulation
Medical Policy
Apr. 1, 2013
February 2013
March 2013
UPDATED/REVISED (continued)
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Policy Title
Policy Type
Effective Date
Medical Policy
Update Bulletin
Medical Policy
Jan. 1, 2013
January 2013
RETIRED
Visualization Technologies for Cervical Cancer
Screenings
Note: The appearance of a service or procedure on this list indicates that UnitedHealthcare has recently adopted, revised or retired a Medical
Policy, Drug Policy, URG or CDG; it does not imply that UnitedHealthcare provides coverage for the services or procedures listed. In the event
of an inconsistency or conflict between the information provided in this bulletin and the posted Medical Policy, Drug Policy, URG or CDG, the
provisions of the posted policy will prevail.
Most UnitedHealthcare benefit plan documents exclude from benefit coverage health services identified as investigational or unproven.
Physicians and other health care professionals may not seek or collect payment from a UnitedHealthcare member for services not covered by the
applicable benefit plan, unless they first obtain the member’s written consent, acknowledging that the service is not covered by the benefit plan
and that they will be billed directly for the service.
Reminder of Advance Notification List
Updates to the 2013 UnitedHealthcare
Administrative Guide for
UnitedHealthcare Commercial Plans
In 2012, UnitedHealthcare communicated its plans
to adopt a standard list of services requiring advance
notification for UnitedHealthcare’s Commercial
plans. The Advance Notification list in the 2013
Administrative Guide will go into effect for service
dates on or after April 1, 2013.
As a reminder, some members have plans that
provide pre-service clinical coverage reviews, while
others do not. The process to initiate a notification
or a prior authorization request is the same,
regardless of the type of plan.
Additionally, the processes for submitting a
notification or a prior authorization request will not
change. If you are planning to perform a service on
the Advanced Notification list, please notify
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UnitedHealthcare in advance. We will let you know
if a clinical coverage review is required and ask you
to submit information to complete the review. We
will let you know when a coverage determination
decision is made. We determine coverage consistent
with the member’s benefit plan. For example,
members are responsible for deductibles,
coinsurance, copayments, and items not covered by
the plan.
A receipt of an approved notification or prior
authorization for services confirms coverage, but it
does not guarantee or authorize payment. Payment
of covered services is subject to the terms and
conditions of your contract with UnitedHealthcare
and the member’s health benefit plan including
exclusions, limitations, conditions, patient eligibility
and claim processing requirements.
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
UnitedHealthcare Notification and Prior Authorization Programs
Not Changing on April 1, 2013:
Other Notification & Prior Authorization Programs
Health Plans
Admission Notification
UnitedHealthcare Commercial
UnitedHealthcare Medicare Advantage
Prior Authorization for Elective Inpatient Admission MAHP (M.D. IPA, Optimum Choice)
Oxford Commercial
UnitedHealthcare West Commercial
UnitedHealthcare West Medicare Advantage
Cardiology Notification Program
UnitedHealthcare Commercial
Cardiology Pre-certification Program
Neighborhood Health Partnership
Cardiology Prior Authorization Program
Oxford Medicare Advantage
UnitedHealthcare Medicare Advantage
UnitedHealthcare of the River Valley
Radiology Notification Program
Neighborhood Health Partnership
UnitedHealthcare Commercials
Radiology Pre-certification Program
Oxford Commercial
Radiology Prior Authorization Program
Oxford Medicare Advantage
UnitedHealthcare Medicare Advantage
Orthopedic Services through OrthoNet
Oxford Commercial
Podiatry Services through Foot and Ankle Network
Neighborhood Health Partnership
Specialty Drug Prior Authorization Program
MAHP (M.D. IPA, Optimum Choice)
Oxford Medicare Advantage
UnitedHealthcare Medicare Advantage
Note: To distinguish between administrative rules applicable to UnitedHealthcare products and products
formerly known as PacifiCare commercial and PacifiCare/SecureHorizons Medicare products, we will use a
reference to “UnitedHealthcare West.” The following legal entities are included in the reference to
“UnitedHealthcare West:” UHC of California doing business as UnitedHealthcare of California,
UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare Benefits of Texas,
Inc., UnitedHealthcare of Washington, Inc., PacifiCare of Arizona, Inc., PacifiCare of Colorado, Inc.,
PacifiCare of Nevada, Inc., and UnitedHealthcare Services, Inc. The products offered by these legal entities
have been rebranded. PacifiCare Health Systems, LLC remains as a stand-alone legal entity today. Behavioral
health products are provided by U.S. Behavioral Health Plan, California (USBHPC) or United Behavioral
Health (UBH).
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
Advance Notification List for UnitedHealthcare Commercial Effective April 1, 2013
Service
Description
Bariatric surgery
Inpatient and outpatient bariatric Surgery and specific obesity-related services.
Behavioral health services
Behavioral health services through a designated behavioral health network.
Bone growth stimulator
Use of electronic stimulation or ultrasound to heal fractures.
BRCA genetic testing
Breast cancer susceptibility testing (BRCA1 and BRCA2).
Breast reconstruction
(non-mastectomy)
Reconstruction of the breast or other than following mastectomy.
Capsule endoscopy
Wireless capsule endoscopy is a noninvasive procedure in which a swallowable,
multivitamin-sized capsule containing a miniaturized wireless video camera, light,
transmitter and batteries records video of the mucosal lining of the esophagus
and/or small bowel as it moves through the gastrointestinal tract.
Chiropractic services
Manipulative treatment, also known as mobilization therapy or "adjustment," refers
to manual therapy employed to soft or osseous tissues for therapeutic purposes.
Please call the number on the member’s ID card when referring for any
chiropractic services.
Clinical trial
A controlled study of a new drug, new medical device or other treatment on human
subjects. The study is overseen by an Institutional Review Board.
Cochlear implants and other A surgically implanted medical device in the ear to help persons with profound
auditory implants
sensorineural deafness to achieve conversational speech.
Congenital heart disease
Congenital heart disease related services, including pre-treatment evaluation.
Cosmetic and
reconstructive procedures
Cosmetic procedures that change physical appearance, without significantly
improving or restoring physiological function.
Reconstructive procedures that either treat a medical condition or improve or
restore physiologic function.
Durable medical equipment DME with a retail purchase cost or a cumulative rental cost over $1,000.00.
(DME)
End-stage renal
disease/dialysis (ESRD)
services
Services for the treatment of ESRD, including outpatient dialysis services.
Healthy pregnancy
Notification allows OptumHealth to enroll pregnant members in the Healthy
Pregnancy Program
Home care
Enteral formula/pumps, skilled nursing and private duty nursing.
Hyperbaric oxygen
treatment
Non-emergent hyperbaric oxygen treatments.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Service
Description
Intensity-modulated
radiation therapy (IMRT)
IMRT
Infertility
Diagnostic and treatment services related to the inability to achieve pregnancy.
Injectable medication
A drug capable of being injected intravenously, through an intravenous infusion,
subcutaneously or intra-muscularly.
Joint replacement
Joint replacement procedures.
MR-guided focused
ultrasound to treat uterine
fibroid
MR-guided focused ultrasound procedures and treatments.
Muscle flap procedure
A muscle or portion of muscle that can be transferred with its blood supply to
another part of the body for reconstructive purposes.
Non-emergency transport
Non-urgent ambulance transportation by air, land, or other means between
specified locations.
Orthognathic surgery
Treatment of maxillofacial (jaw) functional impairment.
Orthotics
Orthotics with a retail purchase cost or a cumulative rental cost over $1000.00.
Out-of-network services
A recommendation from a network physician, or health care professional to a
hospital, physician, or other health care professional who is not contracted with
UnitedHealthcare.
Physical therapy/
occupational therapy
Required when services are performed at an outpatient clinic contracted with
OptumHealth Physical Health. Benefit plans may require pre-service coverage
review. Please call number on the member’s ID card to fulfill the requirement.
Potentially unproven
services
Services, including medications, that are determined not to be effective for
treatment of the medical condition and/or not to have a beneficial effect on health
outcomes due to insufficient and inadequate clinical evidence from studies in the
prevailing peer-reviewed medical literature.
Prosthetics
Prosthetics with a retail purchase cost or a cumulative rental cost over $1000.00.
Proton beam therapy
Focused radiation therapy that uses beams of protons (tiny particles with a positive
charge).
Septoplasty/ rhinoplasty
Treatment of nasal functional impairment and septal deviation.
Sleep apnea procedures &
surgeries
Maxillomandibular advancement or oral-pharyngeal tissue reduction for treatment
of obstructive sleep apnea.
Sleep studies
Laboratory-assisted and related studies, including polysomnography, to diagnosis
sleep apnea and other sleep disorders.
Specific medications as
indicated on the
prescription drug list (PDL)
Refer to the PDL to see which medications require Prior Authorization.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Service
Description
Spinal stimulator for pain Spinal cord stimulators when implanted for pain management.
management
Spinal surgery
Inpatient and outpatient spinal surgeries.
Transplant of tissue or
organs
Organ or tissue transplant or transplant related services prior to pre-treatment or
evaluation.
For transplant services, call OptumHealth at 888-936-7246 or at the number on the
member’s health care ID card.
Vagus nerve stimulation
Implantation of a device that sends electrical impulses into one of the cranial nerves.
Vein procedures
Removal and ablation of the main trunks and named branches of the saphenous veins
for the treatment of venous disease and varicose veins of the extremities.
Ventricular assist
devices
A mechanical pump that takes over the function of the damaged ventricle of the heart
and restores normal blood flow.
Call OptumHealth at 888-936-7246 or at the number on the member’s health care ID
card.
• The process to request prior authorization is the
same as the process to provide advance
notification.
Changes to the Outpatient Radiology
Notification Program and Cardiology
Notification Program for Commercial
Members, Effective July 1, 2013
Effective July 1, 2013, where applicable under the
member’s benefit document, a clinical coverage
review will be conducted to determine if the service
is medically necessary once notification of a
planned service subject to UnitedHealthcare’s
Outpatient Radiology Notification Program or
Cardiology Notification Program requirements is
received. Please note, you must notify us of any
planned service subject to UnitedHealthcare’s
Outpatient Radiology Notification Program and
Cardiology Notification Program requirements
and complete the prior authorization process
even if you practice in a state in which these
programs have not currently been implemented.
Please note the following:
• The list of services requiring prior authorization
is the same as the list of services requiring
advance notification.
• You do not need to determine whether a clinical
coverage review is required in a given case or for
a given member. Once you notify us of a
planned service we will let you know whether a
clinical coverage review is required.
• When the prior authorization process is complete,
a coverage determination is made and you are
informed of the decision. If we determine the
service is medically necessary, a prior authorization
number is provided. If we determine the service is
not medically necessary, the claim submitted for
the service will be denied.
• You must confirm that a prior authorization
number has been obtained prior to rendering the
procedure or payment will be denied. Payment
will also be denied if you do not complete the
prior authorization process.
Revision to: Changes to the Outpatient Radiology
Notification Program and Cardiology Notification
Program article on pg. 12 to include “required” at the
end of the 3rd bullet (March 5, 2013).
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
• Subject to state regulation, receipt of a prior
authorization number does not guarantee or
authorize payment. Payment for covered services
is contingent upon coverage within the member's
benefit plan, your eligibility for payment, any
claim processing requirements and your
participation agreement with UnitedHealthcare.
1. Radiology
In- and Out-of-Scope Plans
The following UnitedHealthcare Commercial
benefit plans are subject to the prior authorization
requirements described in this article:
• UnitedHealthcare Choice
notification are referred to as “Advanced
Outpatient Imaging Procedures.”
Beginning July 1, 2013, once advance notification
of a planned Advanced Outpatient Imaging
Procedure is received, UnitedHealthcare will
conduct a clinical coverage review to determine
whether the service is medically necessary based on
the member’s benefit document.
Providers are not required to notify
UnitedHealthcare of any advanced imaging
procedures rendered in the emergency room, urgent
care center, observation unit or during an inpatient
stay.
2. Cardiology
In- and Out-of-Scope Plans
• UnitedHealthcare Select
• UnitedHealthcare HSA/HRA
The following UnitedHealthcare Commercial
benefit plans are subject to the prior authorization
requirements described in this article:
• Navigate
A list of plans excluded from radiology prior
authorization requirements is available at
UnitedHealthcareOnline.com > Clinician
Resources > Radiology. Excluded plans may have
separate radiology prior authorization
requirements. Please refer to the respective
Supplements to the UnitedHealthcare® Physician,
Health Care Professional, Facility and Ancillary
Provider 2013 Administrative Guide for details.
The list of commercial benefit plans subject to
prior authorization requirements is the same as the
list of plans subject to existing advance notification
requirements.
Changes to Radiology Notification/ Prior
Authorization
The ordering provider must notify
UnitedHealthcare prior to scheduling certain CT,
MRI, MRA, PET scan, nuclear medicine and
nuclear cardiology procedures for
UnitedHealthcare Commercial members. The
advanced imaging procedures requiring advance
• UnitedHealthcare Choice
• UnitedHealthcare Select
• UnitedHealthcare HSA/HRA
• Navigate
A list of plans excluded from cardiology prior
authorization requirements is available at available
at UnitedHealthcareOnline.com > Clinician
Resources > Cardiology. Excluded plans may have
separate cardiology prior authorization
requirements. Please refer to the respective
Supplements to the UnitedHealthcare Physician,
Health Care Professional, Facility and Ancillary
Provider 2013 Administrative Guide for details.
The list of commercial benefit plans subject to
prior authorization requirements is the same as the
list of plans subject to existing advance notification
requirements.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Commercial
(continued from previous page)
Changes to Cardiology Notification/ Prior
Authorization
Obtaining Prior Authorization for Radiology and
Cardiology Procedures
The rendering provider must notify
UnitedHealthcare prior to scheduling any of the
cardiology services for UnitedHealthcare
Commercial members:
• Online at UnitedHealthcareOnline.com
>Notifications/Prior Authorizations > Radiology
Notification & Authorization – Submission &
Status
• Diagnostic catheterizations
• Online at UnitedHealthcareOnline.com
>Notifications/Prior Authorizations Cardiology
Notification & Authorization – Submission &
Status
• Electrophysiology implants
Beginning July 1, 2013, the ordering provider
must also notify UnitedHealthcare prior to
scheduling any of the following cardiology services
for UnitedHealthcare Commercial members:
• By calling 866-889-8054 (7 a.m. to 7 p.m.
Monday – Friday, any time zone).
• Echocardiograms
Failure to Complete the Prior Authorization
Process and Failure to Meet Medical Necessity
Criteria
• Stress echocardiograms
Beginning July 1, 2013, once notification of a
planned echocardiogram, stress echocardiogram,
diagnostic catheterization or electrophysiology
implant is received, UnitedHealthcare will conduct a
clinical coverage review to determine whether the
service is medically necessary based on the member’s
benefit document.
Providers must provide notification for diagnostic
catheterizations and electrophysiology implants
rendered in all settings (e.g., outpatient, inpatient
and office-based). Beginning July 1, 2013, providers
must provide notification for echocardiograms and
stress echocardiograms rendered in all settings
except providers are not required to provide
notification if these services are rendered in an
emergency room, observation unit, urgent care
facility or in an inpatient setting.
Failure to complete the prior authorization process
or verify a prior authorization number has been
obtained before rendering a procedure subject to
prior authorization requirements will result in an
administrative claim reimbursement reduction, in
part or in whole. Members cannot be billed for
claims that are administratively denied.
A clinical denial will be issued if it is determined
that the requested service does not meet medical
necessity criteria. Members can be billed for claims
that are clinically denied provided adequate written
consent is obtained from the member.
Contact your UnitedHealthcare Network
Management representative at 800-637-5792, or
email radiology@customerelation.com or
cardiology@customerelation.com with questions.
Please note the following:
• For details about the Medicare Advantage
Cardiology Prior Authorization Program that
went into effect on Oct. 1, 2012, refer to
UnitedHealthcareOnline.com>Clinician
Resources>Cardiology>Medicare Advantage
Cardiology Prior Authorization Program.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Reimbursement Policy
Unless otherwise noted, the reimbursement policies that follow apply to services reported using the
1500 Health Insurance Claim Form, (CMS 1500), 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.
In the event of an inconsistency or conflict between the information provided in the
NetworkBulletin and the posted policy, the provisions of the posted policy prevail.
Revision to Speech Therapy Policy Physical Medicine and Rehabilitation
In alignment with CMS coding guidelines,
UnitedHealthcare reimburses speech language
therapists/pathologists for Current Procedural
Terminology (CPT) codes 92507, 92508 and 92526.
UnitedHealthcare will not reimburse speech
language therapists/pathologists for CPT codes
97110, 97112, 97150, 97530 or 97532.
Effective late second quarter of 2013, the Physical
Medicine and Rehabilitation: Speech Therapy Policy
will be revised to deny reimbursement for CPT
codes 99201-99499 when reported by speech and
language therapists/ pathologists. This aligns with
guidance from CMS and the American Medical
Association (AMA).
Revision to Increased Procedural
Services Policy - Documentation
Requirements for Modifier 22
The Increased Procedural Services Policy outlines
reimbursement for modifier 22 (increased procedural
services) and modifier 63 (procedures performed on
neonates and infants up to a present body weight of
4 kg). UnitedHealthcare allocates an additional 20
percent of the allowable amount of the unmodified
procedure, not to exceed the billed charges when the
medical record documentation supports the use of
the modifiers. Currently, claims submitted with these
modifiers must include the operative report for the
additional reimbursement to be considered by
UnitedHealthcare.
Effective June 2013, to substantiate the use of
modifier 22 and for consideration of the additional
20 percent reimbursement, UnitedHealthcare will
align with CMS and require a concise statement
outlining how the service differs from the usual
service performed, in addition to the operative report
before additional reimbursement will be considered.
Documentation requirements for modifier 63 will
not change.
Telemedicine Policy - Language
Added Relating to Authorized
Provider Specialties
The policy has been updated to denote the following
provider specialties as eligible to be reimbursed for
telemedicine services:
• Physician
• Nurse practitioner
• Physician assistant
• Nurse- midwife
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Reimbursement Policy
(continued from previous page)
The list of codes published in the November 2012
Network Bulletin was not a comprehensive list
applied to this revision. It did not include codes
assigned a PCTC Indicator of 1 or 3 according to
the CMS National Physician Fee Schedule and that
are also on Addendum BB with a Z2 or Z3
payment indicator. The Z2 and Z3 payment
indicator on Addendum BB indicates that the
technical component for these procedures is paid
separately to the ASC, but under a different
payment methodology in addition to the ASC
payment rate.
• Clinical nurse specialist
• Clinical psychologist
• Clinical social worker
• Registered dietitian or nutritional professional
This is a clarification, rather than a change in the
policy.
Revision to Professional/Technical
Component Policy for Selected
Radiology Services Reported in
a POS 24
As announced in the November 2012 Network
Bulletin and effective first quarter 2013, the
Professional/Technical Component Policy will deny
the global and technical charges for selected
radiological services considered inclusive in the
facility payment to an Ambulatory Surgical Center
(ASC).
Effective June 2013, these additional codes, subject
to the professional/technical concept, will be applied
based on these updates. The link to the ASCFS
Addenda is
http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/ASCPayment/11_
Addenda_Updates.html
The following services will not be separately
reimbursed:
• Services subject to the professional/technical
concept that can be reported with modifier TC or
globally.
• Codes that describe the technical component only
service and that are listed on the CMS
Ambulatory Surgical Center Fee Schedule
(ASCFS) addendum BB reported by a physician
or other healthcare professional in an Ambulatory
Service Center (ASC) (CMS Place of Service
(POS) 024).
UnitedHealthcare will reimburse the professional
component to the interpreting physician or other
health care professional only. The facility is
reimbursed for the technical component for services
that are provided in an ASC.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Medicare Solutions
Submit Medicare Part D Vaccine
Claims to OptumRx for Prompt
Processing
Claim must be submitted correctly to OptumRx.
Part D Vaccine and related administrative fee
claims need to be submitted to OptumRx, the
correct Part D payor. Part D Vaccine
claims/administrative fees misdirected to
UnitedHealth Group will result in delayed payment.
To avoid unnecessary delays, submit part D vaccine
claims along with administrative fees to OptumRx
using the free online TransactRx tool - OptumRx’s
electronic vendor for non-pharmacy providers.
Once enrolled, providers may submit Part D
Vaccine claims and administrative fees for more
timely reimbursement.
• 1224: Wrong administration fee code billed.
This Part D claim is denied per National Correct
Coding Initiative (NCCI).
Claim must be submitted correctly to OptumRx.
To ensure the Part D Vaccine claims and
associated administrative fees are being sent to
the appropriate payer, please refer to the
vaccination reimbursement policy per the link
below: click “I Agree” at the bottom of the page,
and scroll the alphabetical listing to find the
policy entitled “Vaccination (Immunization)”:
Link
• For Billing Inquiries on Part D vaccine
associated claims please contact the OptumRx
help desk:
Click here to learn more about TransactRx, to
view a demonstration or for enrollment
information. Contact the TransactRX Customer
Support Center at 866-522-3386.
• UHC M&R (Medicare and Retirement)
PDP: 877-889-6481
Providers unable to access TransactRx may mail
paper claims to OptumRx:
• UHC M&R (Medicare and Retirement)
MAPD: 877-889-6510
Medicare Advantage Part D (MAPD)
PO Box 29045
Hot Springs, AR 71903
For address changes, please send an e-mail to
network@rxsolutions.com.
This will change the address on file at the Part D
payer and will be where all future payments are
sent.
or
Prescription Drug Plan (PDP)
PO Box 29046
Hot Springs, AR 71903
UnitedHealthcare Medicare Solutions
Reimbursement Policies Available
If Part D vaccine claims are submitted incorrectly
to the medical payor, the following new
adjustment/denial codes may be seen:
• 1109: Pending review for Part D coverage.
This Part D claim was submitted to a medical
platform. No action needed. Expect additional time
for processing.
• 1114: Procedure code invalid combo for vaccine.
This Part D claim is denied per National Correct
Coding Initiative (NCCI).
UnitedHealthcare Medicare Solutions
Reimbursement Policies are available on
UnitedHealthcareOnline.com> Tools &
Resources > Policies, Protocols and Guides >
Medicare Advantage Reimbursement Policies.
The Medicare Solutions Reimbursement Policies
include those related to CMS National Coverage
Determinations (NCDs), CMS Local Coverage
Determinations (LCDs) and UnitedHealthcare
Coverage Summaries.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Medicare Solutions
(continued from previous page)
Content includes:
• Summary of each policy - may include coverage
indications and/or limitations.
Note: The appearance of a service or procedure below indicates
that UnitedHealthcare has recently revised a Medicare Advantage
coverage summary; it does not imply that coverage is provided for
the service or procedure
• Chemical and/or Substance Abuse Detoxification
and Rehabilitation
• Relevant CPT/HCPCS and ICP/PCS coding.
• Particular modifiers and condition codes, when
applicable.
• DME, Prosthetics, Corrective
Appliances/Orthotics (Non-foot Orthotics) and
Medical Supplies Grid
• Research sources used in creating and/or
updating the policy.
• Chemotherapy and Associated Drugs and
Treatments
New policies and updates to policies may be
announced in the Network Bulletin and on the
UnitedHealthcareOnline.com news page.
• Emergent/Urgent Services, Post-stabilization
Care and Out-of-area Services
For additional CMS reimbursement policy
information, visit:
• Gastroesophageal and Gastrointestinal Services
and Procedures
• National Correct Coding Initiative (NCCI):
https://www.cms.gov/Medicare/Coding/Nati
onalCorrectCodInitEd/index.html
Medicare Coverage Database contains all NCD
and LCD local articles and proposed NCD
decisions: http://www.cms.gov/medicarecoverage-database/overview-and-quicksearch.aspx
• Home Health Services and Home Health Visits
• Percutaneous Vertebroplasty and Percutaneous
Kyphoplasty
• Preventive Health Services and Procedures
• Radiologic Therapeutic Procedures
Rights and Responsibilities for
Medicare Members
UnitedHealthcare Medicare Advantage
Coverage Summary Updates
The following list includes updated and/or revised
coverage summaries for UnitedHealthcare
Medicare Advantage Plans, approved on Dec. 17,
2012. A detailed summary of the updates is
available on UnitedHealthcareOnline.com >
Tools & Resources > Policies, Protocols and
Guides > UnitedHealthcare Medicare
Advantage Coverage Summaries.
March 2013
• Pain Management and Pain Rehabilitation
• Stimulators - Electrical and Spinal Cord
Stimulators
• Medicare Physician Fee Schedule (MPFS):
http://www.cms.gov/Medicare/MedicareFee-for-Service-Payment/PhysicianFee
Sched/PFS-Relative-Value-Files.html and
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/downloads/How_to_
MPFS_Booklet_ICN901344.pdf
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• Medications/Drugs (Outpatient/Part B)
18
Our members have rights and responsibilities, found
here, which are intended to help uphold the quality
of care and services they receive from their physicians,
health care professionals and providers. Please
consider distributing this statement to your patients.
If your patient has questions about his or her rights
as a Medicare member, or needs help with
communication, such as assistance from a language
interpreter, please refer them to the customer
service phone number on the back of their ID card.
Members receive information about their rights
and responsibilities upon enrollment and annually.
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Community Plan
Prior Authorization Review Required for Selected Injectable Medications for
UnitedHealthcare Community Plan Members
Effective for service dates on or after April 1, 2013, physicians will be required to obtain prior authorization
before administering certain drugs covered under the medical benefit for UnitedHealthcare Community
Plan members, including those members currently on therapy.
Note: Prior Authorization for these medications is not required for services that take place in an emergency room, observation unit, and
urgent care facility or during an inpatient stay.
Impacted medications include the following:*
Please note health plan exceptions for Synagis®, Acthar HP® and Xolair® below.
J-Code
J Code Description
Brand Name
J0585
Botulinum Toxin Type A, per Unit
Botox
J0586
Injection Abobotulinumtoxina, 5 Units
Dysport
J0587
Botulinum Toxin Type B, 100 Units
Myobloc
J0588
Injection, Incobotulinumtoxina, per Unit
Xeomin
J0800
Injection Corticotropin, up to 40 Units
Acthar HP1
J1459
Injection IG IV Nonlyophilized 500mg
Privigen
J1557
Injection, Immune Globulin, intravenous, nonlyophilized,
500mg
Gammaplex
J1559
Injection, Immune Globulin, 100 mg
Hizentra
J1561
Injection Immune Globulin, IV, 500 mg
Gammaked, Gamunex, Gamunex-C
J1566
Injection, Immune Globulin, IV, lyophilized, 500mg
Carimune NF, Gamimune N,
Gammagard S/D, Iveegam
J1568
Injection, Immune Globulin, IV, nonlyophilized, 500mg
Octagam
J1569
Injection, Immune Globulin, IV, nonlyophilized, 500mg
Gammagard Liquid
J1572
Injection, Immune Globulin, IV, nonlyophilized, 500mg
Flebogamma/Flebogamma Dif
J1599
Injection, Immune Globulin, IV, nonlyophilized, not
otherwise specified, 500mg
Gamunex
J1725
Injection, Hydroxyprogesterone Caproate, 1mg
Makena
J2357
Injection Omalizumab 5mg
Xolair2
CPT-Code
Drug Name
90283
Immune Globulin, Human, for intravenous use
Intravenous Immune Globulin
90284
Immune Globulin, Human, for use in subcutaneous
infusions
Subcutaneous Immune Globulin
90378
RSV Immune Globulin for intramuscular use, 50mg
Synagis3
1 Acthar HP – Prior authorization on the medical benefit apply to all health plans except Arizona.
2 Xolair – Prior authorization on the medical benefit only for Delaware, Tennessee, Nebraska, Texas and Wisconsin.
3 Synagis – Prior authorization on the medical benefit only for Delaware, Texas and Wisconsin.
*This list is subject to change as new immune globulin medications, CPT code and/or J codes are released.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Community Plan
Medical Necessity Review Explained
Medical necessity review addresses clinical evidence
supporting the use of a health service, its medical
appropriateness for a particular patient and its costeffectiveness. A treatment is considered medically
necessary if it meets the following criteria:
• Performed in accordance with Generally Accepted
Standards of Medical Practice.
• Clinically appropriate, in terms of type,
frequency, extent, site and duration, and
considered effective for your condition, disease or
its symptoms.
• Not administered mainly for convenience of the
member or health care professional.
• Not more costly than an alternative drug,
service(s) or supply that is at least as likely to
produce equivalent therapeutic or treatment
results.
In accordance with Medicaid requirements, if a
physician fails to obtain prior authorization
approval before administering the product, we will
deny payment for the claim and you may not bill
the member for the service. UnitedHealthcare’s
standard appeal processes apply to any denied
claim.
UnitedHealthcare Community
Plan to Use National
Comprehensive Cancer
Network Compendium
Effective June 1, 2013, UnitedHealthcare
Community Plan will use the National
Comprehensive Cancer Network (NCCN) Drug
Compendium to review requests for coverage for
chemotherapy drugs ( J9000 – J9999) administered
in an outpatient setting. The NCCN Drug
Compendium provides an independent, respected
resource for making chemotherapy coverage
decisions.
Important policy details include:
• If the NCCN Drug Compendium lists the drug
with a recommendation level 1, 2A or 2B for the
condition, the service is eligible for
reimbursement based on the member’s coverage
documents. Recommendations with level 3
evidence are not generally covered unless certain
circumstances apply.
• The primary cancer diagnosis is required on all
claims. Claims submitted with only a V58.1
diagnosis code may require additional
information before a coverage decision can be
made.
• This policy applies to chemotherapy drugs
( J9000 – J9999). It does NOT apply to
supportive care drugs (i.e., ESA’s, antiemtics and
colony stimulating factors).
For prior authorization questions, contact your
local network manager, call the provider services
number on the member’s ID card or visit
UHCCommunityPlan.com.
• NCCN updates their drug compendium based
on evolving scientific evidence and the
availability of new drugs.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Military & Veterans
TRICARE West Region Website
Now Active
UnitedHealthcare Military & Veterans launched
the TRICARE West Region website
www.uhcmilitarywest.com on Feb. 15, 2013. The
website will be updated with new information for
TRICARE network providers and will be fully
functional when the contract transitions to
UnitedHealthcare on April 1, 2013.
NOTE: TRICARE Prime and TRICARE Prime
Remote beneficiaries may need to select a
UnitedHealthcare Primary Care Manager (PCM)
before April 1, 2013. The PCM Directory is now
available on the www.uhcmilitarywest.com website
for beneficiaries to determine if their current PCM
has contracted with UnitedHealthcare. Also
available in the provider section of the website are
the TRICARE West Region Provider Handbook
and Quick Reference Guides.
UnitedHealthcare Pharmacy
Specialty Medication Prescriptions
Many UnitedHealthcare members participate in
our Specialty Designated Pharmacy Program.
Participants in this program are required to fill
their specialty medication prescription(s) at
OptumRx or one of our other designated specialty
pharmacies (depending on therapeutic class) for
maximum benefits.
The Specialty Designated Pharmacy Program is
designed to improve adherence and provide support
and resources offered by specially trained
pharmacists. This program also helps control
escalating costs of specialty medications for our.
Please send all specialty prescriptions directly to
OptumRx or the appropriate designated specialty
pharmacy.
After you call or fax a prescription(s) to OptumRx,
or the appropriate designated specialty pharmacy,
the member will need to call either the designated
specialty pharmacy or the number on the back of
their ID card to coordinate payment and delivery
of their specialty medication.
Members who try to fill their specialty medication
at a retail pharmacy instead of a designated
specialty pharmacy will be directed to call
OptumRx Customer Service or the number on the
back of their health plan ID card for assistance.
OptumRx Customer Service will assist patients
when urgent access to their specialty medication(s)
is needed to avoid a lapse in therapy.
Providers can send specialty prescriptions directly
to OptumRx via:
• Phone: 888-702-8423
• Fax: 800-853-3844
To determine other in-network designated
pharmacies, please see the list below, visit
UHCSpecialtyRx.com or call the Provider
Services number listed on your patients’ health plan
ID card.
(continued on next page)
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Pharmacy
(continued from previous page)
Specialty Designated Pharmacies– Designated Provider by Therapeutic Class
Therapeutic Class
Provider(s)
Phone Number
Cystic Fibrosis
Hematologic
Hepatitis B
HIV/AIDS
Immune Modulator
Iron Overload
Osteoporosis
Parkinson’s
Psoriasis
Rheumatoid Arthritis
Thrombocytopenia Prevention
Transplant
OptumRx
BioScrip
CVS/Caremark (NJ)
888-739-5820
866-788-7710
877-287-1234
Anemia
Endocrine
Growth Hormone
Hepatitis C
Multiple Sclerosis
Neutropenia
OptumRx
BioScrip
CVS/Caremark (NJ)
Burmans (DE, IN & NJ)
888-739-5820
866-788-7710
877-287-1234
800-604-6068
Infertility
Freedom
Burmans (DE, IN & NJ)
CVS/Caremark in NJ
800-355-6832
800-604-6068
877-287-1234
Oral Oncology
OptumRx
BioScrip
888-980-8731
866-788-7710
Pulmonary Arterial Hypertension
Accredo
CVS/Caremark in NJ
866-591-9075
877-287-1234
Hemophilia
OptumRx
BioScrip
Burmans (DE & IN)
855-855-8754
866-788-7710
800-604-6068
Please visit UHCSpecialtyRx.com, for more information on UnitedHealthcare’s Specialty Pharmacy
Program and the conditions included in the program.
UnitedHealthcare Pharmacy Physician Prescription Drug List Online
Visit UnitedHealthcareOnline.com > Tools and Resources > Pharmacy Resources to see the PDL for
employer and individual business (excluding UnitedHealthcare West Signature Value) criteria for drugs
requiring prior authorization and clinical programs, such as step therapy and quantity limits.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Pharmacy
Important Update in Preauthorization
and Acquisition of Hyaluronic
Acid Products
New Fax Line to Assist with
Expedited/Urgent Pharmacy Appeals
Please note the UnitedHealthcare 2013 Physician,
Health Care Professional, Facility and Ancillary
Provider Administrative Guide and the 2013
UnitedHealthcare Physician, Healthcare
Professional, Facility and Ancillary Provider
Administrative Guide Mid-Atlantic Regional
Supplement contain an important pharmacy
protocol change for prescribing hyaluronic acid
medications (sodium hyaluronate) preparations for
the treatment of osteoarthritis.
New protocols – Orthovisc and Gel-One
Beginning April 1, 2013, physicians must acquire
Orthovisc® from a designated specialty
pharmacy. This is the same process we currently
require for acquisition of Supartz® and Hyalgan®.
In the event the member has Medicare coverage,
the physician may continue to purchase any
hyaluronic acid products and directly bill
UnitedHealthcare.
Also beginning April 1, 2013, physicians
prescribing Orthovisc to M.D. IPA and Optimum
Choice, Inc. members must obtain preauthorization
for the medication. This is the same process
required for Supartz and Hyalgan.
Effective April 1, 2013, physicians prescribing GelOne® to M.D.IPA and Optimum Choice members
treated in an outpatient setting will be required to
obtain preauthorization. GelOne is available in
physician offices and facilities.
These protocols apply to UnitedHealthcare
members in commercial benefit plans insured or
administered by Mid-Atlantic Medical Services
(MAMSI), Neighborhood Health Partnership,
UnitedHealthcare of the River Valley and
UnitedHealthcare.
A fax line for urgent pharmacy appeals is available.
When you submit an expedited or urgent pharmacy
appeal on behalf of a patient, review the initial
denial letter to verify the instructions for filing
expedited or urgent pharmacy appeals. Please put
“URGENT” or “EXPEDITED” in bold letters at
the top of the document or on the fax cover sheet.
UnitedHealthcare offers a pharmacy
expedited/urgent appeal process to handle
pharmacy appeals where the patient’s condition
warrants a quick turnaround time. The patient or
the patient’s representative (including a physician
or other health care professional) may request an
expedited/urgent pharmacy appeal.
The criteria for determining if a pharmacy appeal
will be handled as expedited/urgent may vary based
on state and federal mandates and/or accreditation
standards. Considerations include whether a delay
in treatment could seriously jeopardize a patient’s
life or health and/or cause severe pain.
*Please note this only applies to UnitedHealthcare commercial
business.
Prior Authorization Required for H.P.
Acthar Gel and Immune Globulin
Medications for UnitedHealthcare
Commercial
Effective April 1, 2013, UnitedHealthcare will
implement a change in the advanced notification
review process for the administration of certain
specialty medications covered under the medical
benefit.
Beginning April 1, 2013, participating network
physicians will be required to obtain prior
authorization review and approval prior to
administration of H.P. Acthar® and immune
globulins to UnitedHealthcare commercial
members, including members already on therapy.
These requests may be subject to medical necessity
review to determine coverage.
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March 2013
23
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Pharmacy
(continued from previous page)
Prior authorization for H.P. Acthar and immune
globulin medications is not required for services
that take place in an emergency room, observation
unit and urgent care facility or during an inpatient
stay.
The following codes/medications will require prior
authorization and medical necessity review,
beginning April 1, 2013:*
J-Code
Drug Name
J0800
H.P. Acthar
J1459
Privigen
J1557
Gammaplex
J1559
Hizentra
J1561
Gamunex
Gamunex-C
Gammaked
J1566
Carimune
Gammagard S/D
J1568
Octagam
J1569
Gammagard Liquid
J1572
Flebogamma
J1599
Intravenous Immune Globulin
Not Otherwise Specified
CPT-Code
Drug Name
90283
Intravenous Immune Globulin
90284
Subcutaneous Immune Globulin
2.
Submit the enrollment form and supporting
medical records to UnitedHealthcare.
Documents may be faxed to 866-756-9733.
For assistance, call 877-842-3210.
3.
A clinician will review the prior authorization
request.
a. If coverage is approved, the physician will
receive confirmation via phone and fax.
b. If coverage is denied, the physician will
receive confirmation via phone and fax,
including information on appeal rights.
Note: in accordance with the physician’s
agreement, if the physician fails to obtain prior
authorization approval before administering the
product, we will deny payment for the claim and
you may not bill the member for the service.
UnitedHealthcare’s standard appeal process will
apply to any denied claims.
Complete information about prior authorization
for specialty medications is available in the 2013
Administrative Guide under Specialty Drug
Prior Authorization Process (commercial). View
the guide at: UnitedHealthcareOnline.com >
Tools & Resources > Pharmacy Resources >
Policies, Protocols and Guides.
For question contact your local network manager or
call the administrative services number on the back
of the member’s ID card.
*This list is subject to change as new immune globulin medications,
CPT-Code and/or J-Codes are released.
Update: Alternatives Added for Jan. 1,
2013 Pharmacy Benefit
Prior Authorization Process
Prior authorization is mandatory for dates of
service beginning April 1, 2013. Follow these steps
to obtain prior authorization:
Alternatives for Bayer test strips were added to the
Signature Value Formulary and select
UnitedHealthcare pharmacy benefits administered
by OptumRx. Updates were communicated in the
Nov. 1, 2012 Network Bulletin .
1.
Access and review the UnitedHealthcare’s drug
policies and appropriate prescription
enrollment form at
UnitedHealthcareOnline.com > Tools &
Resources > Pharmacy Resources >
Policies, Protocols and Guides.
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Effective Jan. 1, 2013, ACCU-CHEK® (Roche)
test strips, Glucocard® (Arkay) test strips and
OneTouch® (Lifescan) test may be used as
alternates for Breeze®2, Contour®(Bayer) Test
Strips.
For more information, visit UnitedHealthcareOnline.com
Doing Business Better
Keeping Your Information Up-to-date
UnitedHealthcare is committed to providing
members with accurate, up-to-date information about
our provider network. Please make sure that your
information is current by providing 30 days’ notice
prior to the effective date of changes for: Tax ID,
address changes, new service location and additions or
departures of health care providers from your practice.
Submit changes for UnitedHealthcare via:
• UnitedHealthcareOnline.com>
Practice/Facility Profile link at the top of the
home page. For online assistance, see the Facility
or Physician Data Quick Reference or call the
help desk at 866-842-3278 from 9 a.m. to 10
p.m. EST.*
• Fax the Provider Demographic Change Form to
855-773-3156. For Tax ID changes you will need
to submit a W-9 form.
• Call the UnitedHealthcare for Health Care
Professionals line (United Voice Portal) 877-8423210, say "health care professional services" and
then "demographic changes."
*Tax IDs cannot be updated online.
Submit changes for Oxford via:
• OxfordHealth.com. To add or change your
practice address, phone number, fax and email,
Logon and click “change” on the My Account
tab. Call the help desk at 800-811-0881 if you
need assistance.*
Updates to myHealthcare Cost
Estimator
The myHealthcare Cost Estimator (myHCE) tool
helps members prepare for expected out-of-pocket
costs prior to proceeding with medical treatment.
Enhancements to myHCE are expected to be
completed by mid- 2013 and include the following:
• UnitedHealthcare members in direct contract
markets will have access to the myHCE tool by
the end of the first quarter2013
• United Medical Resources (UMR) customers
and UnitedHealthcare’s Third Party
Administrator will have access to the myHCE
tool by second quarter2013
• Client and group-specific agreements will be
added to the tool mid-2013.
• Expanded care paths will include select highvolume inpatient services by mid-2013.
Cost estimator features and benefits include:
• Cost estimates are available for approximately
180 services and procedures in all
UnitedHealthcare markets, including selected
procedures for common ambulatory, outpatient
services such as radiology, lab, office visits,
consultations and preventative services.
• Estimated out-of-pocket costs and health plan
payments based on the member's specific benefit
plan design, as well as real-time health care
account balances.
• Fax the Provider Demographic Change Form to
866-561-3966 for changes to Tax IDs, National
Provider Identifiers (NPI) or taxonomy codes. A
W-9 form is required for Tax ID changes.
• Ability to assemble cost estimates by matching
physicians with the specific facilities where they
practice.
• Phone: 800-666-1353 and say “help me with
something else” and then “facility and practice
changes.”
• Treatment options, which may lead to informed
conversations between members and their
physician about alternative treatments.
*NPIs cannot be added or changed on OxfordHealth.com. If you
participate with UnitedHealthcare, use UnitedHealthcareOnline.com
for NPI updates
• Cost estimates based on the allowed fee schedule
or contracted rate amount for the physician,
hospital or other health care professional.
Facilities may also use the fax or phone options above.
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For more information, visit UnitedHealthcareOnline.com
Doing Business Better
(continued from previous page)
When fee schedules are not systematically available
a claims-based methodology will be utilized.
For more information visit:
UnitedHealthcareOnline.com > Tools &
Resources > Health Resources for Patients >
Transparency (myHCE).
In the unique circumstance that your patient
requires a specific laboratory service and you
believe there is no network facility, contact
UnitedHealthcare to coordinate care. If we are
unable to identify a network facility that meets the
needs of your patient, we will work with you to
obtain the needed service out-of-network.
A myHCE demonstration can be accessed at
welcometomyUHC.com > myHealthcare Cost
Estimator - Demos and Promotional Videos
For questions, please contact your Physician or
Hospital and Facility Advocate.
Reminder to Use Network Laboratories
Credentialing Plan Changes Effective
April 1, 2013
UnitedHealthcare provides access to a broad
network of laboratories, and using them may
reduce our members’ out-of-pocket costs. We offer
the following resources and suggestions:
• Review the UnitedHealthcare Protocols online at
UnitedHealthcareOnline.com:
– Protocol on the Use of Non-participating
Laboratory Services
– Protocol for Providing Advance Notice to
Customers when Involving Non-participating
Providers in Customers’ Care
• Access the list of participating laboratories online
at UnitedHealthcareOnline.com > Physician
Directory > General Physician Directory >
Select a Plan > Laboratory > Enter Zip Code
> Select Laboratory
• Discuss the importance of using
UnitedHealthcare’s network for covered service
with members.
The 2013-2014 Credentialing Plan and State and
Federal Regulatory Addendum will be effective
April 1, 2013. UnitedHealthcare reviews and
updates our Credentialing Plan a minimum of
every two years to ensure continued compliance
with state and federal regulatory requirements and
NCQA Accreditation requirements.
Key changes include:
Section 4.0 Initial Credentialing of Licensed
Independent Practitioner Applicants:
• Clarified that physicians who have opted out of
Medicare will not be able to participate in
networks maintained by UnitedHealthcare for
Medicare Advantage or TRICARE benefit plans.
• Clarified language regarding
exclusion/termination (for cause) from Medicare
or any state's Medicaid or CHIP program. Any
exclusion or termination (for cause) will be
reason to deny credentialing or recredentialing.
Section 9.5 Ongoing Monitoring:
• Direct members to myUHC.com for a directory
of laboratories and more information.
• Encourage members to use network facilities to
optimize health care benefits and reduce financial
costs that may be incurred by going out-ofnetwork.
• Added Section C: Imminent Threat to Patient
Safety. Pursuant to this new section,
UnitedHealthcare may suspend participation
status based on a publically verifiable allegation
or an investigation by a government agency when
the allegation or investigation raises concern that
there may be an imminent threat to a member’s
safety.
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For more information, visit UnitedHealthcareOnline.com
Doing Business Better
(continued from previous page)
Section 9.6 Ongoing Monitoring:
• New Section 9.6 relates to the use of in-network
facilities for procedures that are not performed in
an office setting. If the facility where you treat
UnitedHealthcare members no longer
participates in UnitedHealthcare’s network, your
participation status may be terminated unless you
find another in-network facility to use.
Facility Credentialing:
• Due to TRICARE requirements, we are now
credentialing birthing centers.
The Credentialing Plan will be posted to
UnitedHealthcareOnline.com no later than
April 1, 2013.
Advance Directives
The federal Patient Self-Determination Act
(PSDA) gives individuals the legal right to make
choices about their medical care in advance of
incapacitating illness or injury.
Under this act, physicians and health care
professionals, hospitals, skilled nursing facilities,
hospices, home health agencies and others must
provide patients written information on state law
about advance treatment directives, the patients’
right to accept or refuse treatment and your policies
regarding advance directives. Encourage members
to execute an advance directive and a limited
durable power of attorney. UnitedHealthcare also
informs our members about advance directives
through other communications, including through
our member handbooks.
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Reminder: Important Change to DME
Provider Network
As of Feb. 1, 2013, American Homepatient will no
longer participate in the UnitedHealthcare DME
network and will be a non-participating DME
provider. Your patients with medical benefits
covered through UnitedHealthcare,
SecureHorizons®, Evercare® and United
Healthcare Community Plans who use American
Homepatient should be transitioned to another
DME provider. Due to the structure of many
benefit plans, members who receive services
provided by a non-network DME provider may
incur increased financial liability and be exposed to
higher out-of-pocket expenses.
UnitedHealthcare continues to offer members
access to a broad choice of quality network DME
providers. In the Northeast, Southeast and Central
regions we have developed a relationship with
Rotech Healthcare. Affected physicians and health
care professionals and their patients have been sent
letters in advance of these changes. Contact Rotech
Healthcare at 877-254-1725 or visit their website
rotech.com.
Additional national DME providers include Apria
Healthcare and Lincare. National and local
providers in your area may be found at
UnitedHealthcareOnline.com. Please refer your
patients to in-network DME providers as outlined
in your network participation agreement.
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Claims, Billing and Coding
Radiology Program Procedure Code Changes - Effective Jan.1, 2013
Effective Jan. 1, 2013, UnitedHealthcare updated the procedure code list for the Radiology Notification and
Prior Authorization programs based on code changes made by the AMA. Claims with dates of service on or
after Jan.1, 2013 are subject to these changes.
Added codes:
CODE
CPT/HCPCS
CODE DESCRIPTION
78012
Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression,
or discharge, when performed)
78013
Thyroid imaging (including vascular flow, when performed)
78014
Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s)
quantitative measurement(s) (including stimulation, suppression or discharge, when performed)
78071
Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)
78072
Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT),
and concurrently acquired computed tomography (CT) for anatomical localization
Deleted codes:
CODE
CPT/HCPCS
CODE DESCRIPTION
78000
Thyroid uptake; single determination
78001
Thyroid uptake; multiple determinations
78003
Thyroid uptake stimulation, suppression or discharge (not including initial uptake studies)
78006
Thyroid imaging, with uptake; single determination
78007
Thyroid imaging, multiple determinations
78010
Thyroid imaging; only
78011
Thyroid imaging; with vascular flow
Revised code descriptions:
CODE
CPT/HCPCS
CODE DESCRIPTION
78070
Parathyroid planar imaging (including subtraction, when performed)
76376
3D rendering with interpretation and reporting of computed tomography, magnetic resonance
imaging, ultrasound, or other tomographic modality with image post processing under concurrent
supervision; not requiring image post processing on an independent workstation
76377
3D rendering with interpretation and reporting of computed tomography, magnetic resonance
imaging, ultrasound, or other tomographic modality with image post processing under concurrent
supervision; requiring image post processing on an independent workstation
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Claims, Billing and Coding
(continued from previous page)
All programs use the same list of procedure codes.
The complete list of procedure codes requiring
notification or prior authorization is available on
UnitedHealthcareOnline.com via these links:
• UnitedHealthcare
• UnitedHealthcare Medicare Advantage
• UnitedHealthcare Community Plan
Appropriate Modifiers Required for
DME Billing
UnitedHealthcare identified payment issues
relating to DME claims in which providers are
billing without the appropriate modifiers.
UnitedHealthcare follows CMS regulations, which
state that providers are required to submit claims
with the appropriate modifiers when the
“indications and limitations of coverage and/or
medical necessity” have been met.
We updated our processes and policies to ensure
they are fully compliant with these regulations.
These updates went into effect on Jan. 1 2013.
After this date, providers are required to submit
claims with the appropriate modifiers. Claims
billed without the appropriate modifiers will be
rejected for missing information.
If all of the criteria in the “Indications and
Limitations of Coverage and/or Medical Necessity”
section have not been met, the GA or GZ modifier
must be added to the code. When there is an
expectation of a medical necessity denial, suppliers
must enter the GA modifier on the claim line if
they have obtained a properly executed Advance
Notice of Non-Coverage (ANN) or the GZ
modifier if they have not obtained a valid ANN.
Claim lines billed with applicable CPT codes that
do not include the KX, GA or GZ modifier will be
rejected as missing information.
Chemotherapy Drug Review on
Hospital Claims
Effective second quarter 2013, UnitedHealthcare
will change the review process for chemotherapy
drugs administered in an outpatient facility setting
to align with the review process for chemotherapy
drugs administered in a physician office setting.
Changes include:
• Outpatient claims with a date of service after the
effective date will be reviewed using the NCCN
Drug Compendium.
This process will impact physician claims billed on
CMS-1500 form and 873P, UnitedHealthcare
Medicare Solutions line of business. More
information can be found on UHCOnline.com.
• A primary cancer diagnosis is required on claims.
Claims submitted with only a V58.1 diagnosis
code may need more information before a
coverage decision can be made.
Example Policy:
KX, GA and GZ modifiers:
• Claims submitted on a UB-04 form without
injectable drug details (e.g., J code, NDC, charge
amount or service units) may need more
information before a coverage decision can be
made.
Suppliers must add a KX modifier to the Ankle
Foot/Knee Ankle Foot Orthosis base and addition
codes if all of the coverage criteria in the
“Indications and Limitations of Coverage and/or
Medical Necessity” section of this policy has been
met. This evidence must be retained in the
supplier’s files and available to the DME MAC
upon request.
• If the NCCN Drug Compendium lists the drug
with a recommendation level 1, 2A or 2B for the
condition, the service is eligible for reimbursement
on the basis of the member’s coverage documents.
(continued on next page)
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Claims, Billing and Coding
(continued from previous page)
Drugs that are not listed or that have a level 3
recommendation are not covered unless the member
has an exception in their coverage document. The
NCCN updates its drug compendium frequently
based on scientific evidence and the availability of
new cancer medications.
• New drugs and/or indications for a drug are not
eligible for reimbursement until a
recommendation of 1, 2A or 2B for the condition
is listed in the NCCN Drug Compendium.
To have an outpatient chemotherapy regimen
reviewed prior to service, submit predetermination
requests via:
• Community Plan: UHCCommunityPlan.com>
Health care professional>choose your state>
Claims and Member information>Claim
Reconsideration documents
UnitedHealthcare continues to look for innovative
ways to make it easier for you to do business with
us. We are piloting an electronic application that
allows claim reconsideration requests to be
submitted with attachments. We hope to share
more information on this improvement soon.
*Due to state regulations, this does not apply to all Medicaid states.
Please access this information on your state’s page on
UHCCommunityPlan.com> Health Care Professional>choose
your state>Claims and Member information>Claim
Reconsideration documents.
Phone: 877-842-3210 from 8 a.m. to 8 p.m. EST
National Comprehensive Cancer
Network Drug Compendium
Fax: 866-756-9733
Online: UnitedHealthcareOnline.com to submit a
Notification request
Improved Process for Claim
Reconsideration Requests
UnitedHealthcare has simplified the claim
reconsideration request process by consolidating
request forms into a single document for use across
all lines of business.*
This generic, easy-to-use document was designed
to complement the process available online, and
should be used with requests for reconsideration
submitted by mail.
Effective June 1, 2013, UnitedHealthcare affiliates
Golden Rule Insurance Company, American
Medical Security Life Insurance Company and All
Savers Insurance Company will use the NCCN
Drug Compendium for reviewing requests for
coverage for chemotherapy drugs ( J9000 – J9999)
administered in an outpatient setting. The NCCN
Drug Compendium provides an independent,
respected resource for use in making chemotherapy
coverage decisions.
Important policy details include:
We also created a reference guide that details where
to send your requests and explains the requirements
needed for prompt processing. This document can
be found on the websites listed below along with
the claim reconsideration request form.
These documents may be found at:
• Commercial/Medicare Solutions:
UnitedHealthcareOnline.com > Claims &
Payments > Claim Reconsideration > Claim
Reconsideration Request Form.
• If the NCCN Drug Compendium lists the drug
with a recommendation level 1, 2A or 2B for the
condition, the service is eligible for
reimbursement based on the member’s certificate
of coverage. In general, we do not cover
recommendations with level 3 evidence, unless
certain conditions exist.
• NCCN updates their Drug Compendium based
on scientific evidence on existing drugs and the
availability of new drugs.
(continued on next page)
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Claims, Billing and Coding
(continued from previous page)
• This new drug policy requires that the primary
cancer diagnosis be included on the claim.
Claims submitted with only a V58.1 diagnosis
code may require additional information prior to
a coverage decision.
This policy applies to chemotherapy drugs ( J9000
– J9999). It does NOT apply to supportive care
drugs (i.e., ESA’s, antiemtics or colony stimulating
factors)
UnitedHealthcare, Oxford Health Plans,
UnitedHealthcare of the Mid-Atlantic and
UnitedHealthcare of the River Valley review
authorization requests and/or Avastin claims using
the NCCN Drug Compendium. Reviews include
treatment regimen and the line of therapy.
Effective second quarter 2013, UnitedHealthcare
will include the review of maintenance therapy and
limit maintenance therapy to a single agent. If
Avastin is given with any other chemotherapy drug
after first line treatment (four to six cycles of
chemotherapy), the Avastin claim will be denied.
Transcutaneous Electrical Nerve
Stimulation for Chronic Low Back Pain
Medicare Solutions Policy Summary
CMS issued National Coverage Determination
(NCD) 160.27 Transcutaneous Electrical Nerve
Stimulation (TENS) for Chronic Low Back Pain
(CLBP) effective June 8, 2012, limiting coverage of
TENS for CLBP to members who are enrolled in
a CMS approved clinical trial and meet certain
criteria.
When coverage requirements are met, original
Medicare will be responsible for payment of TENS
for CLBP under the clinical trial, NCD 310.1
Routine Costs in Clinical Trials. Otherwise, TENS
for CLBP is not covered and UnitedHealthcare
Medicare Advantage Plans are not responsible for
payment.
March 2013
For additional information, visit the following
websites:
• CMS:
http://www.cms.gov/Medicare/Medicare.html
Use of Avastin as Maintenance
Therapy for Non-Small Cell Lung
Cancer
I
This applies to all members for service dates on or
after June 8, 2012 who currently rent or want to
purchase TENS units and associated supplies. For
services on and after June 8, 0212, providers may
submit relevant TENS claims to original Medicare
for possible coverage and /or payment under the
clinical trial NCD.
31
• NCD 160.27:
http://www.cms.gov/medicare-coveragedatabase/details/ncd-d160.27
• Transmittal 149:
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals
• MLN Matters:
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7
836.pdf
Mandatory Inpatient CPT Coding Must
Be Accompanied by Mandatory
Written Inpatient Order
CMS identifies procedures under the Medicare
Outpatient Prospective Payment System (OPPS)
which are typically provided only in an inpatient
setting, and therefore would not be paid under
OPPS. This list must be used to determine if a
procedure is inpatient only for Medicare payment.
Each year CMS, with input from the Ambulatory
Payment Classification Panel, reviews the inpatient
list using criteria to determine whether procedures
should be moved from the inpatient list and paid
under OPPS. The inpatient list is in Addendum E
on the CMS web site:
http://www.cms.gov/apps/ama/license.asp?file
=/Medicare/Medicare-Fee-for-ServicePayment/HospitalOutpatientPPS/Downloads
/CMS-1589-FC-Addenda.zip.
(continued on next page)
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Claims, Billing and Coding
(continued from previous page)
For regulatory and compliance purposes, and to
maintain or improve the Medicare beneficiary's
functional abilities, a written order is required with
inpatient admissions. Orders should include dietary
guidelines, medication information (if necessary)
and routine care information.
When a CMS mandatory inpatient-only procedure
is performed, a written inpatient order for this
admission is necessary to ensure proper
consideration of payment.
A written order is required with any inpatient
admission for regulatory compliance purposes.
Accurate Billing Improves Office
Efficiency and Dual SNP Member
Satisfaction
At UnitedHealthcare, making sure our members
are satisfied with their plan at each touch point is
integral to our mission of helping people live
healthier lives.
Inaccurate billing is one touch point that can lead to
dissatisfaction, patient confusion and frustration.
Billing errors also generate workflow inefficiencies that
lead to unnecessary administrative costs for providers.
To help prevent billing errors, please ask members
in the Dual Special Needs Plan (SNP) residing in
AZ, MI, NJ, NY, PA, TN and WI to show their
state Medicaid card and their UnitedHealthcare
Community Plan ID card at every visit.
Verification of dual coverage when services are
rendered also expedites claim payments and reduces
patient calls to your office.
SNP enrollees will also receive education about the
benefits of presenting both cards at each office visit.
Additionally, accurate billing impacts how members
rate their satisfaction with UnitedHealthcare
Community Dual SNP Plan on the CAHPS
(Consumer Assessment of Healthcare Providers
and Systems) Health Plan Survey. The CAHPS
Health Plan Survey is the national standard for
measuring and reporting on the experiences of
consumers with their health plans.
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Proton Beam Radiation Therapy Prior
Authorization
Effective April 1, 2013, UnitedHealthcare will
require prior authorization for Proton Beam
Radiotherapy (PBT) services. Requests for prior
authorization will be reviewed based on the
UnitedHealthcare medical policy on PBT.
Initiate Prior Authorization via:
• Phone: 877-842-3210
• Fax: 866-756- 9733
• Online: UnitedHealthcareOnline.com to
submit a notification case.
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Clinical
Patient Education Materials Available
for Behavioral and Substance Abuse
Issues
• When Do You Need to See a Specialist? postcard includes tips for seeking treatment and offers
resources for finding a behavioral health specialist.
Misuse or abuse of drugs, including pharmaceuticals,
illicit drugs or alcohol, account for more than half of
drug-related emergency department visits each year1.
People with substance abuse or alcohol use disorders
can benefit from treatment. However, they may be
reluctant to talk to their physician or may be unaware
of treatment options.
• When Do You Need to See a Specialist? brochure includes additional information on what a
behavioral health specialist is and how to locate
one.
Based on feedback from physicians,
UnitedHealthcare developed patient education
postcards and brochures that can be displayed in
waiting rooms or shared with patients during office
visits. This material was designed to encourage
patients to talk to their physician and to provide
helpful resources. Patient education materials include:
To learn more about available resources visit
UnitedHealthcareOnline.com > Clinician
Resources or visit http://www.niaaa.nih.gov.
1
Center for Behavioral Statistics and Quality, Substance Abuse and
Mental Health Services Administration. Highlights of the 2010
Drug Abuse Warning Network (DAWN) findings on drug-related
emergency department visits. The DAWN Report, July 2, 2012.
• Talking about Substance Abuse Issues postcard encourages patients to talk to their physician and
provides resources for treatment.
• Alcohol and Drug Use – Help is out there for You and
Your Loved One brochure - includes the popular 4item CAGE (need to Cut down, Annoyed by
criticism, Guilty about drinking and need for an
Eye opener) screening tool. Additional screening
strategies and tools can be found at
http://www.niaaa.nih.gov.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Affiliates
Insulin Vials/Pens/Cartridges
Reminder Regarding Milliman Care
Guidelines
Non-Preferred Products - Require Pre-certification
As noted in the 2013 Oxford Provider Reference
Manual, Oxford Health Plans adopted the
Milliman Care Guidelines® and criteria for
inpatient and ambulatory care where no specific
Oxford policy exists. For additional information see
OxfordHealth Plans>Provider
Resources>Provider Reference Manual.
Effective July 1, 2013, Oxford Health Plans in
Connecticut and New York will implement new
pre-certification requirements for Oxford
commercial members who use certain nonpreferred diabetes medications and test strips.
Prescribing a preferred drug, as appropriate, can
help your patients gain access to medications they
need at an affordable cost.
Note that non-preferred products will require precertification. Preferred products require a
prescription only.
Information regarding the preferred and nonpreferred product options includes:
Glucose Test Strips and Meters*
Non-preferred Products - Require Pre-certification
Ascensia Autodisc Contour
Breeze 2
Contour Next
Abbott Diabetes
Freestyle Insulinx
Freestyle Lite
Select oral diabetic agents for controlling blood
sugar (DPP-4 Inhibitors)
Non-preferred Products - Require Pre-certification
Januvia
Janumet/Janumet XR
Preferred Products - No Pre-certification Required
Onglyza or Tradjenta
Kombiglyze or Jentadueto
Letters will be mailed to Oxford members affected
by the new pre-certification requirements in late
April 2013 (i.e., those members currently taking a
non-preferred drug listed in the table above). On
July 1, 2013, pre-certification will be required for a
member to continue to receive coverage for a nonpreferred product. We anticipate members may
consider the preferred alternatives and ask your
advice.
If appropriate, please write a new prescription for a
preferred alternative for these members. If a
preferred alternative is not appropriate, beginning
July 1, 2013 a pre-certification must be obtained to
determine benefit coverage and can be requested by
taking the following steps:
Freestyle
Precision Xtra
Preferred Products - No Pre-certification Required
Lifescan
Preferred Products - No Pre-certification Required
Humalog
Humalog Mix 75-25, 50-50
Humulin 70-30
Humulin N
Humulin R
New Pre-certification Requirements
for Non-preferred Diabetes
Medications and Test Strips for
Oxford Members Pharmacy
Bayer Healthcare
Apidra/Apidra Solostar
Novolog
Novolog Mix 70-30
Novolin 70-30
Novolin N
Novolin
One Touch Ultra
One Touch Verio IQ
Roche Diagnostics Accu-Chek Aviva Plus
Accu-Chek Smartview
• Verify your patient’s eligibility and benefit
coverage by calling 800-666-1353.
* Free meters will be provided to your patients.
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UnitedHealthcare Affiliates
(continued from previous page)
• After eligibility and benefits are confirmed and
your initial evaluation is complete, please request
a pre-certification review for the diabetes
medications and supplies.
• Phone: 866-242-9546 Monday-Friday,
7:00am-7:00pm, EST
• Online: mynhp.com > access e-services.
• Please complete the pre-certification form and
return via fax to 800-837-0959.
For information regarding preauthorization
requirements go to mynhp.com>providers.
Oxford will evaluate the request and notify both
you and your patient by mail with our decision.
UnitedHealthcare of the River Valley
Preauthorization List and Policy
Updates
Additional Precertification Codes for
Neighborhood Health Plan
The following updates to UnitedHealthcare of the
River Valley’s preauthorization list, Reimbursement
Policies, Drug Policies, Medical Policies, Utilization
Review Guidelines (URG) and/or Coverage
Determination Guidelines (CDG) apply to
UnitedHealthcare of the River Valley commercial
membership. Once implemented, the updated list,
policies and guidelines may be viewed at
UHCrivervalley.com > Providers > Coverage
Policy Library unless otherwise noted.
Effective July 1, 2013, Neighborhood Health
Partnership will add echocardiograms to its
Cardiac Precertification list. Echocardiograms
performed in an outpatient setting will require
preauthorization for the following CPT codes:
93303, 93304, 93306, 93307 and 93308.
CareCore National will process preauthorization
requests and make medical necessity
determinations based on evidence-based clinical
guidelines.
Policy Title
Submit requests via:
In the event of an inconsistency or conflict between the
information provided in the Network Bulletin and the posted
preauthorization requirements, policies or guidelines, the provisions
of the posted preauthorization requirements, policies or guidelines
will prevail. The updates listed apply to UnitedHealthcare of the
River Valley commercial plan membership only; they do not apply
to members enrolled in a River Valley Ohio product or South
Carolina product.
Effective Date
What’s Changed
May 1, 2013
Proven Uses:
• Aflibercept is proven for the treatment of;
– Neovascular age-related macular degeneration (AMD)
– Macular edema secondary to branch retinal vein occlusion (BRVO)
or central retinal vein occlusion (CRVO)
• Bevacizumab is proven for the treatment of;
– Neovascular age-related macular degeneration (AMD)
– Diabetic macular edema
– Macular edema secondary to branch retinal vein occlusion (BRVO)
NEW
Ophthalmologic
Policy: Vascular
Endothelial Growth
Factor (VEGF)
Inhibitors
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
NEW (continued)
Ophthalmologic
Policy: Vascular
Endothelial Growth
Factor (VEGF)
Inhibitors (continued)
or central retinal vein occlusion (CRVO)
– Proliferative diabetic retinopathy
– Neovascular glaucoma
– Choroidal neovascularization secondary to pathologic myopia,
angioid streaks/pseudoxanthoma elasticum, or ocular
histoplasmosis syndrome (OHS)
• Pegaptanib is proven for the treatment of;
– Neovascular age-related macular degeneration (AMD)
– Diabetic macular edema
• Ranibizumab is proven for;
– Neovascular age-related macular degeneration (AMD)
– Diabetic macular edema
– Macular edema secondary to branch retinal vein occlusion (BRVO)
or central retinal vein occlusion (CRVO)
– Choroidal neovascularization secondary to pathologic myopia,
angioid streaks/ pseudoxanthoma elasticum, or ocular
histoplasmosis syndrome (OHS)
Unproven Use:
Aflibercept, bevacizumab, pegaptanib, and ranibizumab are unproven for
the treatment of retinopathy of prematurity.
Repository
May 1, 2013
Corticotropin
Injection (H.P. Acthar
Gel)
Repository corticotropin injection (H.P. Acthar Gel) is proven for the
treatment of:
1. Infantile spasm (i.e., West Syndrome)
Additional information to support medical necessity review:
Repository corticotropin injection is medically necessary for the
treatment of infantile spasms for up to 4 weeks when all of the
following criteria are met:
A. Diagnosis of infantile spasms (i.e., West Syndrome); and
B. Patient is less than 2 years old; and
C. Repository corticotropin injection dosing for infantile spasm is as
follows:
a. Initial dose: 75 U/m intramuscular (IM) twice daily for 2 weeks.
b. After 2 weeks, dose should be tapered according to the
following schedule: 30 U/m IM in the morning for 3 days; 15 U/m
IM in the morning for 3 days; 10 U/m IM in the morning for 3
days; and 10 U/m IM every other morning for 6 days (3 doses).
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
NEW (continued)
Repository
May 1, 2013
Corticotropin
Injection (H.P. Acthar
Gel) (continued)
2. Multiple sclerosis (MS), acute exacerbation
Additional information to support medical necessity review:
Repository corticotropin injection is medically necessary for treatment
of acute exacerbations of multiple sclerosis for up to 3 weeks when all
of the following criteria are met:
A. Diagnosis of multiple sclerosis with acute exacerbation; and
B. History of failure, contraindication, or intolerance to corticosteroids
for treatment of acute exacerbation of multiple sclerosis; and
C. Repository corticotropin injection dosing for acute exacerbation is
as follows: 80-120 units intramuscular (IM) or subcutaneous (SQ)
daily for 2-3 weeks on a tapering schedule.
3. Opsoclonus-myoclonus syndrome (i.e., OMS, Kinsbourne Syndrome)
For the proven indications listed below, refer to the medical necessity
criteria, where applicable, at the end of the list:
4. Ankylosing spondylitis*
5. Anterior segment inflammation*
6. Chorioretinitis*
7. Dermatomyositis, systemic (polymyositis)*
8. Diffuse posterior uveitis and choroiditis*
9. Iridocyclitis*
10. Iritis*
11. Juvenile idiopathic arthritis*
12. Keratitis*
13. Nephrotic syndrome without uremia of the idiopathic type or that
due to lupus erythematosus*
14. Optic neuritis*
15. Psoriatic arthritis*
16. Rheumatoid arthritis*
17. Sarcoidosis, symptomatic*
18. Serum sickness*
19. Severe erythema multiforme*
20. Stevens-Johnson syndrome*
21. Systemic lupus erythematosus (SLE)*
*Additional information to support medical necessity review:
Repository corticotropin injection is medically necessary when all of the
following criteria are met:
A.Proven indication as listed above; and
B.History of failure, contraindication, or intolerance to corticosteroids
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
Bariatric Surgery
May 1, 2013
• Reorganized policy content
• Updated description of services to reflect most current clinical
evidence and references
• Reformatted and revised coverage rationale:
– Updated/expanded class II obesity (BMI 35-39.9 kg/m2) co-morbidity
descriptions for cardiovascular disease and life-threatening
cardiopulmonary problems
– Added criteria for medical necessity review (when applicable)
– Removed language indicating vertical banded gastroplasty (gastric
banding; gastric stapling), biliopancreatic bypass (Scopinaro
procedure), and biliopancreatic diversion with duodenal switch are
not first-line procedures for the general bariatric surgery patient
– Replaced references to “morbid obesity” with “extreme obesity”
(per updated National Heart, Lung and Blood Institute (NHLBI)
classification)
Continuous Glucose
Monitoring and
Insulin Delivery for
Managing Diabetes
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Deep Brain
Stimulation
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
• Revised list of applicable CPT/HCPCS codes requiring preauthorization:
– Added 95978 and 95979
– Removed 61864 and 61868 (preauthorization no longer required)
• Updated list of applicable ICD-10 diagnosis codes (preview draft
effective 10/01/14); removed G24.09 and G25.1
Electrical &
Ultrasound Bone
Growth Stimulators
May 1, 2013
• Changed policy title; previously titled Bone Growth Stimulators
• Updated description of services to reflect most current clinical
evidence and references
• Revised coverage rationale; added information pertaining to medical
necessity review
• Updated list of applicable HCPCS codes; removed guidelines specific
to Medicare plan members
Epiduroscopy,
Epidural Lysis of
Adhesions
May 1, 2013
• Updated description of services to reflect most current clinical
evidence and references; no change to coverage rationale
• Updated list of applicable CPT codes requiring preauthorization; added
62292 and 64999
UPDATED/REVISED
(continued on next page)
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date What’s Changed
UPDATED/REVISED (continued)
Gastrointestinal
Motility Disorders,
Diagnosis and
Treatment
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
• Updated list of applicable CPT codes requiring preauthorization; added
0242T
Genetic Testing for
Hereditary Breast
and-or Ovarian
Cancer Syndrome
(HBOC)
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Herceptin
(Trastuzumab) and
Perjeta™
(Pertuzumab)
May 1, 2013
• Changed policy title; previously titled Herceptin® (Trastuzumab)
• Updated description of services to reflect most current clinical evidence
and references
• Revised coverage rationale; added HER2 testing requirement for
pertuzumab
• Updated list of applicable HCPCS codes; added C9292 (pertuzumab)
High Frequency
Chest Wall
Compressions
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Immune Globulin
(IVIG and SCIG)
May 1, 2013
• Changed policy title; previously titled Immune Globulin (IVIG)
• Removed Vivaglobin from list of applicable drug products
• Updated description of services to reflect most current clinical evidence
and references; added FDA Safety Communication
• Reformatted and revised coverage rationale:
– Added Alzheimer’s disease to list of unproven uses
– Added paraproteinemic neuropathy to list of proven uses (previously
unproven)
– Added information pertaining to medical necessity review
• Added list of applicable CPT codes requiring preauthorization through
Pharmacy Care Management: 90283 and 90284
• Updated list of applicable ICD-9 codes:
– Added 204.12, 279.11, 279.8, 279.9, 288.09, 288.1, 323.01, 323.02, 323.9,
357.9, 484.1, 646.80, 646.81, 646.82, 646.83, 646.84, 678.00, 678.03, 757.39,
776.8 and 776.9
– Removed 038.10, 041.01, 279.02, 337.01, 694.0, 772.10, 772.11, 772.12,
772.13, 772.14, 995.91 and 995.92
• Updated list of applicable ICD-10 diagnosis codes (preview draft
effective 10/01/14)
Implantable BetaEmitting
Microspheres for
Treatment of
Malignant Tumors
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
UPDATED/REVISED (continued)
Intensity-Modulated
Radiation Therapy
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Magnetoencephalography and
Magnetic Source
Imaging for Specific
Neurological
Applications
May 1, 2013
• Changed policy title; previously titled Magnetoencephalography and
Magnetic Source Imaging
• Revised coverage rationale; added information pertaining to medical
necessity review
Mandibular
Disorders
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
• Updated list of applicable CPT codes requiring preauthorization;
removed 21247
Manipulation Under
Anesthesia
May 1, 2013
• Updated description of services to reflect most current clinical
evidence and references; no change to coverage rationale
• Updated list of applicable CPT codes requiring preauthorization; added
21073, 23700, 24300, 26340, 27194 and 27570
• Updated list of applicable ICD-9 diagnosis codes; removed 726.10 and
733.19
• Updated list of applicable ICD-10 diagnosis codes (preview draft
effective 10/01/14)
Mechanical
Stretching and CPM
Devices
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Omnibus Codes
May 1, 2013
• Updated list of services considered to be proven in certain
circumstances; added 64999 (unlisted procedure, nervous system):
– Added language to indicate treatment (that may include
laminectomy and sacral reconstruction) of a Tarlov cyst from the
sacrum is proven for patients who experience pain or neurologic
symptoms attributed to the Tarlov cyst
– Added information pertaining to medical necessity review
Outpatient
July 1, 2013
Cardiology Stress
Echocardiogram and
Outpatient
Echocardiogram
Effective for service dates on or after July 1, 2013, physicians must obtain
prior authorization for outpatient stress echocardiograms and outpatient
echocardiograms. CPT codes subject to this requirement include:
• Stress echocardiogram codes: 93350, 93351
• Echocardiogram codes: 93303, 93304, 93306, 93307, 93308 CareCore
National will process preauthorization requests for these procedures
and make medical necessity determinations based on evidence-based
clinical guidelines.
Submit requests via:
• Phone: 866-889-8054 • Online: UHCRiverValley.com > e-services
For information regarding these preauthorization requirements visit
UHCRiverValley.com > preauthorization > procedures.
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
UPDATED/REVISED (continued)
Plagiocephaly and
Craniosynostosis
May 1, 2013
• Reformatted and revised coverage rationale; added information
pertaining to medical necessity review
• Updated list of applicable HCPCS codes requiring preauthorization;
added A8000, A8001 and A8002
Preventive Care
Services
Apr. 1, 2013
• Added Appendix A: USPSTF Grade Definitions
Proton Beam
Radiation Therapy
May 1, 2013
• Revised list of applicable procedure and diagnosis codes (effective for
dates of service on or after 4/1/13):
Cervical Cancer Screening, Pap Smear
– Removed 2003 USPSTF rating for sexually active women (no age
limit)
– Added March 2012 USPSTF rating for women age 21 to 65 years;
updated claim edit criteria to reflect age limit guideline of 21 to 65
years (no frequency limit)
Colorectal Cancer Screening
– Moved 88304 and 88305 into new/separate procedure code group
category (Code Group 3)
– Added claim edit criteria for Code Group 3 to indicate 88304 and
88305 must billed with one of the listed diagnosis code and one
procedure code from Code Group 1 or Code Group 2
Immunizations
– Removed G9141 from list of applicable procedure codes (code
expired 12/31/12)
Screening for Obesity in Adults
– Removed 2003 USPSTF rating
– Added June 2012 USPSTF rating for body mass index (BMI) of 30
kg/m2
– Added list of applicable diagnosis codes for BMI of 30.0 – 39.0:
V85.30 – V85.39
Women’s Preventive Health: Breastfeeding Support, Supplies, and
Counseling
– Added list of applicable diagnosis codes for breast pump equipment
& supplies: V24.1
– Updated claim edit criteria; added language to indicate diagnosis
code V24.1 is required for E0603, E0604 and A4281 – A4286
Radiofrequency
May 1, 2013
Therapy and Tibial
Nerve Stimulation for
Urinary Disorders
• Revised coverage rationale; added information pertaining to medical
necessity review
• Revised coverage rationale; added information pertaining to medical
necessity review
• Updated list of applicable CPT codes requiring preauthorization; added
64566
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
UPDATED/REVISED (continued)
Sandostatin®/
Sandostatin LAR®
Depot (octreotide
acetate)
May 1, 2013
• Changed policy title; previously titled Sandostatin®/Sandostatin LAR®
(octreotide acetate)
• Revised list of proven uses/conditions; added:
– Meningiomas
– Lung neuroendocrine tumors
– Malignant bowel obstruction
• Revised list of unproven uses/conditions; removed malignant bowel
obstruction
• Added medically necessity criteria for refractory HIV/AIDS-related
diarrhea
• Updated list of applicable ICD-9 codes:
– Added 209.31, 209.32, 209.33, 209.34, 209.35, 209.36, 209.62, 209.71,
209.73, 209.74, 209.75, 225.0, 225.2, 225.4, 558.9, 560.0, 560.2, 560.9, and
564.9
– Removed 196.2, 196.9, 197.0, 197.7, 209.63, 211.1, 242.80, and 242.81
• Updated list of applicable ICD-10 codes (preview draft effective
10/1/14)
Surgical Treatment
for Spine Pain
May 1, 2013
• Revised coverage rationale:
– Added language to indicate spinal fusion using extreme lateral
interbody fusion (XLIF) or direct lateral interbody fusion (DLIF) are
proven
– Added coding clarification language to indicate:
• The North American Spine Society (NASS) recommends that anterior
or anterolateral approach techniques performed via an open approach
should be billed with CPT codes 22554 – 22585; these codes should be
used to report the use of extreme lateral interbody fusion (XLIF) and
direct lateral interbody fusion (DLIF) procedures (NASS, 2010)
• Laparoscopic approaches should be billed with an unlisted procedure
code
• Updated list of applicable CPT codes requiring preauthorization; added
22586, 63265, 63267, 63268, 63270, 63271, 63272, 63286, 63300, 63301,
63302, 63303, 63304, 63305, 63306, 63307 and 63308
• Updated list of applicable (unproven) CPT codes; added 0309T
• Updated list of applicable ICD-10 diagnosis codes (preview draft
effective 10/01/14)
Surgical Treatment
of Obstructive Sleep
Apnea
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
Transcatheter Heart
Valve Procedures
May 1, 2013
• Revised coverage rationale; added information pertaining to medical
necessity review
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Title
Effective Date
What’s Changed
Feb. 1, 2013
The procedural codes and/or services previously outlined in this policy
are no longer being managed or are considered to be proven (covered).
They are not excluded as unproven (not covered) services unless
coverage guidelines or criteria are otherwise documented in another
policy.
Note: The absence of a policy does not automatically indicate or imply
coverage. As always, coverage for a service or procedure must be
determined in accordance with the member’s benefit plan and any
applicable federal or state regulatory requirements. UnitedHealthcare
reserves the right to review the clinical evidence supporting the safety
and effectiveness of a medical technology prior to rendering a coverage
determination.
RETIRED
Visualization
Technologies for
Cervical Cancer
Screening)
Oxford Medical and Administrative Policy Updates
The following table outlines the Medical and Administrative Policies recently adopted or revised by
Oxford®. A detailed summary of the updates is available in the Policy Update Bulletin at
OxfordHealth.com. The bulletin is published on the first day of the month at oxfordhealth.com >
Providers > Tools & Resources > Practical Resources > Medical and Administrative Policies > Policy
Update Bulletin.
Policy Title
Policy Update
Bulletin
Policy Type
Effective Date
Bosutinib (Bosulif)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Breast Pump
Administrative
Policy
Apr. 1, 2013
January 2013
February 2013
March 2013
Enzalutamide (Xtandi)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Regorafenib (Stivarga)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Sandostatin Subcutaneous Formulation (Octreotide
Acetate)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Xeljanz (Tofacitinib)
Clinical Policy
Mar. 1, 2013
February 2013
17-Alpha-Hydroxyprogesterone Caproate (Makena™
and 17P)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Abnormal Uterine Bleeding and Uterine Fibroids
Clinical Policy
Apr. 1, 2013
March 2013
NEW
UPDATED/REVISED
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Type
Effective Date
Policy Update
Bulletin
Agents for Migraine - Triptans
Clinical Policy
Apr. 1, 2013
March 2013
Anticonvulsants - Depakote ER, Keppra, Keppra XR,
Lamictal, Lamictal XR, Generic Levetiracetam XR,
Lamictal ODT, Topamax, Stavzor
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Autism
Administrative
Policy
Feb. 1, 2013
January 2013
Biologics in the Treatment of Skin, Joint and
Gastrointestinal Conditions
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Continuous Glucose Monitoring and Insulin Delivery for
Managing Diabetes
Clinical Policy
Apr. 1, 2013
March 2013
Core Decompression for Avascular Necrosis
Clinical Policy
Mar. 1, 2013
February 2013
Deep Brain Stimulation
Clinical Policy
Apr. 1, 2013
March 2013
Drug Coverage Criteria – New and Therapeutic
Equivalent
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Mar. 1, 2013
February 2013
Apr. 1, 2013
March 2013
Feb. 1, 2013
January 2013
Feb. 15, 2013
January 2013
February 2013
Mar. 1, 2013
February 2013
Apr. 1, 2013
March 2013
Policy Title
UPDATED/REVISED
Drug Coverage Guidelines
Clinical Policy
Elbow Replacement Surgery (Arthroplasty)
Clinical Policy
Mar. 1, 2013
February 2013
Electrical and Ultrasound Bone Growth Stimulators
Clinical Policy
Apr. 1, 2013
March 2013
Electrical Stimulation for the Treatment of Pain and
Muscle Rehabilitation
Clinical Policy
Apr. 1, 2013
March 2013
Elidel (Pimecrolimus) and Protopic (Tacrolimus)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Formula & Specialized Food
Clinical Policy
Mar. 1, 2013
February 2013
Gastrointestinal Motility Disorders, Diagnosis and
Treatment
Clinical Policy
Apr. 1, 2013
March 2013
Genetic Testing for Hereditary Breast and/or Ovarian
Cancer Syndrome (HBOC)
Clinical Policy
Apr. 1, 2013
March 2013
Glaucoma Surgical Treatments
Clinical Policy
Apr. 1, 2013
March 2013
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(continued from previous page)
Policy Type
Effective Date
Policy Update
Bulletin
High Frequency Chest Wall Compression Devices
Clinical Policy
Apr. 1, 2013
March 2013
Hip Replacement Surgery (Arthroplasty)
Clinical Policy
Mar. 1, 2013
February 2013
Home Health Care
Clinical Policy
Feb 1, 2013
January 2013
Icatibant (Firazyr) and C1 Esterase Inhibitors Human
(Berinert)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Immune Globulin (IVIG and SCIG)
Clinical Policy
Apr. 1, 2013
March 2013
Implantable Beta-Emitting Microspheres for Treatment
of Malignant Tumors
Clinical Policy
Apr. 1, 2013
March 2013
In-Office Laboratory Testing and Procedures List
Reimbursement Mar. 1, 2013
Policy
February 2013
Interferon Alphas and Ribavirin
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Knee Replacement Surgery (Arthroplasty)
Clinical Policy
Mar. 1, 2013
February 2013
Lubiprostone (Amitiza) and Linaclotide (Linzess)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Mandibular Disorders
Clinical Policy
Apr. 1, 2013
March 2013
Manipulation Under Anesthesia
Clinical Policy
Apr. 1, 2013
March 2013
Mechanical Stretching and Continuous Passive Motion
Devices
Clinical Policy
Apr. 1, 2013
March 2013
Modifier SU Policy
Reimbursement Feb. 1, 2013
Policy
January 2013
Multiple Sclerosis: Interferon B-1A (Avonex, Rebif),
Interferon B-1B Betaseron, Extavia, Glatiramer
(Copaxone), Fingolimod (Gilenya), and Teriflunomide
(Aubagio)
Clinical Policy
Feb 1, 2013
January 2013
Non-Surgical Treatment Of Obstructive Sleep Apnea
Clinical Policy
Apr. 1, 2013
March 2013
Omnibus Codes
Clinical Policy
Apr. 1, 2013
March 2013
Omega-3-Acid Ethyl Esters (Lovaza and Vascepa)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Oral Chemotherapy Drugs: Application of NCCN Clinical
Practice Guidelines
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Plagiocephaly and Craniosynostosis Treatment
Clinical Policy
Apr. 1, 2013
March 2013
Policy Title
UPDATED/REVISED
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UnitedHealthcare Affiliates
(continued from previous page)
Policy Type
Effective Date
Policy Update
Bulletin
Precertification Exemptions for Outpatient Services
Administrative
Policy
Mar. 1, 2013
February 2013
Preventive Care
Clinical Policy
Apr. 1, 2013
February 2013
March 2013
Proton Pump Inhibitors
Clinical Policy
Apr. 1, 2013
March 2013
Radiofrequency Therapy and Tibial Nerve Stimulation for
Urinary Disorders
Clinical Policy
Apr. 1, 2013
March 2013
Residential Treatment for Mental Health and Substance
Abuse Disorders
Clinical Policy
Mar. 1, 2013
February 2013
Roflumilast (Daliresp)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Sandostatin LAR Depot (Octreotide Acetate)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Shoulder Replacement Surgery (Arthroplasty)
Clinical Policy
Mar. 1, 2013
February 2013
Sodium Hyaluronate
Clinical Policy
Apr. 1, 2013
January 2013
February 2013
March 2013
Standby Services
Administrative
Policy
Apr. 1, 2013
March 2013
Stelara (Ustekinumab)
Clinical Policy
Feb. 15, 2013
January 2013
February 2013
Surgical Treatment for Spine Pain
Clinical Policy
Apr. 1, 2013
March 2013
Surgical Treatment of Obstructive Sleep Apnea
Clinical Policy
Apr. 1, 2013
March 2013
Total Artificial Heart
Clinical Policy
Apr. 1, 2013
March 2013
Transcatheter Heart Valve Procedures
Clinical Policy
Apr. 1, 2013
March 2013
Transcutaneous Electrical Nerve Stimulation (TENS) for
the Treatment of Nausea and Vomiting
Clinical Policy
Mar. 1, 2013
February 2013
Transportation Services
Clinical Policy
Mar. 1, 2013
February 2013
Utilization Management Appeal Process and Timeframes
for Connecticut Plans
Administrative
Policy
Feb. 1, 2013
February 2013
Utilization Management Appeal Process and Timeframes
for New York Plans
Administrative
Policy
Feb. 1, 2013
February 2013
Vaccines
Clinical Policy
Apr. 1, 2013
February 2013
Policy Title
UPDATED/REVISED
Note: The appearance of a service or procedure on this list indicates that Oxford has recently adopted or revised a policy; it does not imply
that Oxford provides coverage for the services or procedures listed.
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.
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Affiliates
SignatureValue Medical Management
Guideline Updates
SignatureValue Benefit Interpretation
Policy Updates
The following is a list of recently adopted and/or
revised Medical Management Guidelines for
UnitedHealthcare SignatureValue™ Plans, effective
Jan. 1, 2013. A detailed summary of the updates is
available on UHCWest.com > Provider Log In >
Library > Resource Center > Guidelines &
Interpretation Manual: November 2012
The following is a list of recently adopted and/or
revised Benefit Interpretation Policies for
UnitedHealthcare SignatureValue™ Plans. A
detailed summary of the updates is available on
UHCWest.com > Provider Log In > Library >
Guidelines & Interpretation Manual > Benefit
Interpretation Policy Updates: November 2012
and December 2012 respectively.
Note: The appearance of a service or procedure below indicates that
UnitedHealthcare has recently adopted or revised a SignatureValue
Medical Management Guideline; it does not imply that coverage is
provided for the service or procedure.
• Wireless Capsule Endoscopy
Note: The appearance of a service or procedure below indicates that
UnitedHealthcare has recently adopted or revised a SignatureValue
Benefit Interpretation Policy; it does not imply that coverage is
provided for the service or procedure listed.
• Hip Resurfacing Arthroplasty doc
Updated/Revised – November 2012,
effective Dec. 1, 2012:
• Mandibular Disorders
• RehabMedical PT-OT-SP
• Transcutaneous Electrical Nerve
Stimulation
• Breast Pump
• Core Decompression for Avascular
Necrosis
• Shoulder Replacement
Surgery(Arthroplasty)
Updated/Revised – December 2012,
effective Feb. 1, 2013:
• Warming Therapy and Ultrasound Therapy
for wounds
• Medical Necessity
• Hospital Observation
• Implantable Beta Emitting Microspheres
• Pervasive Developmental Disorder
• Hip Replacement Surgery(Arthroplasty)
• Rehabilitation: Cognitive Therapy
• Omnibus Codes
• Second Opinion: Member Initiated Second
Opinion
• Cardiovascular Disease Risk Tests
• Knee Replacement Surgery (Arthroplasty)
• Elbow Replacement Surgery
• Sexual Dysfunction: Erectile Dysfunction
(Impotence)
• Computed Tomographic Colonography
• Sleep Apnea
• Genetic Testing for HBOC
• Surgery: Orthognathic Surgery
• Orthognathic Jaw Surgery
• Surgery: Post-Mastectomy Surgery
• Rhinoplasty
• Telemedicine/Telehealth Services
• Ablative Procedures for Venous
Insufficiency and Varicose Veins
• Transplants: Organ and Tissue Transplants
• Preventive Care Services
• NCCN- CPG
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For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare Affiliates
UnitedHealthcare West Requires Prior
Authorization for Bevacizumab
Effective May 1, 2013, UnitedHealthcare West will
implement a prior authorization requirement for
Avastin (Bevacizumab) for oncology use. This
process will impact clinics providing care to
UnitedHealthcare West members where
UnitedHealthcare has retained financial
responsibility for Avastin.
The administration of Avastin will be reviewed for
compliance with the NCCN drug compendium’s
recommended uses for the drug as it pertains to
treatment regimen and/or line of therapy.
Noncompliant services will not be eligible for
coverage.
This policy does not apply to Bevacizumab used for
non-oncological indications.
Odds and Ends
Enhancements to
UnitedHealthcareOnline.com
• Notification/Prior Authorization Search
Option*: The Physician/Provider Only option
allows you to search for all notifications and prior
authorizations for a selected physician, health
care professional or facility without specifying a
patient. Select the Physician/Provider Address,
Type of Notification and Notification Status.
Results will include the following new fields:
Eligibility for, Subscriber # and Place of Service.
Click any header to re-sort records.
• Coordination of Benefits Enhancements for
UnitedHealthcare Commercial Members:
These new fields have been added to the claims
transactions: Primary Impact on claim, Allowed
Amount, Medicare Paid Amount, Other
Insurance Paid Amount and Physician/Provider
Not Covered.
• ID Cards for UnitedHealthcare Community
Plan Members Available: You can view and
print ID cards for Community Plan members
from the eligibility transaction.
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For additional details, screenshots and other
enhancements, see the release notice of Dec. 12,
2012. Release notices are posted in the News
section of the UnitedHealthcareOnline.com.
* Not available for UnitedHealthcare Community Plan
Manage Receivables More Efficiently
with Direct Deposit and Online
Explanation of Benefits
Electronic Remittance Advice and Funds Transfer
(ERA/EFT) tools allow you to choose a method
for receipt of explanation of benefits (EOBs) and
receive payments quicker via direct deposit. EOB
information can be viewed online, printed as a
PDF or posted to your system using the HIPAA
835 file.
• Learn more about UnitedHealthcare’s
Electronic Payments & Statements (EPS)
• Read about Oxford’s PNC Remittance
Advantage
For more information, visit UnitedHealthcareOnline.com
UnitedHealthcare’s 835 File Resources
The following, updated documents assist you with 835 files:
UnitedHealthcareOnline.com > Tools & Resources > EDI
Education for Electronic Transactions > Electronic Remittance
Advice (835):
• Updated Contact Information for different scenarios.
• New Terms and Acronyms webpage.
• Types of 835 Files - explains differences between EFT and non-EFT
files and claim platform.
• Provider-Level Adjustments: Basics – explains adjustment codes
commonly used in PLB segments.
• Provider-Level Adjustments: Overpayment Recovery – explains the
overpayment recovery process and gives examples of PLB segment
usage in different scenarios.
If you do not contract directly with UnitedHealthcare, or participate in our network through another arrangement some of the information provided in this
communication may not be applicable to you and/or may affect you differently. If you have questions or require further information, please contact your local
Network Management representative, Physician Advocate or Hospital & Facility Advocate. If you are uncertain who your contact is, please visit
UnitedHealthcareOnline.com > Contact Us > Network Contacts.
Insurance coverage provided by UnitedHealthcare Insurance Company or its
affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc.;
UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc.; UnitedHealthcare
of Oregon, Inc.; UnitedHealthcare of Utah, Inc.; and UnitedHealthcare of Washington,
Inc. or other affiliates. Administrative services provided by United HealthCare
Services, Inc. or its affiliates.
MN012-N108
P.O. Box 1459
Minneapolis, MN55440-1459
M47484 3/13 UHC2439a © 2013 UnitedHealth Group, Inc. All Rights Reserved
For more information, visit UnitedHealthcareOnline.com