Network Bulletin: November 2016 network bulletin Medical Equipment Providers • Get Better Results...

Important updates from UnitedHealthcare to health care professionals and facilities

UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information.

Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law.

network bulletinNetwork Bulletin: November 2016

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Network Bulletin: November 2013 - Volume 582

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For more information, call 877.842.3210 or visit UnitedHealthcareOnline.com

2 Network Bulletin: October 2016

Front & Center

• eligibilityLink and claimsLink Rollout Continues

• Revisions to the Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy — Professional Component Reduction Change

• Important Changes to Our Network of Durable Medical Equipment Providers

• Get Better Results for 270/271 Eligibility and Benefits Transactions

• Change to Caremark Home Infusion and Specialty Pharmacy Medical Benefit Agreement

• New Dual Special Needs Program Will Launch in January 2017

• Update to Prior Authorization Requirement for Functional Endoscopic Sinus Surgery

• Changes in Advance Notification and Prior Authorization Requirements

• Reminder: Please Complete CMS-required Model of Care Training

• Communication Effectiveness Survey

UnitedHealthcare Commercial

• No Changes to Prior Authorization Process for Proton Beam Therapy

• UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates

• UnitedHealth Premium® Designation Program – 2017 Designations

UnitedHealthcare Commercial Reimbursement Policies

• Revision to Maximum Frequency per Day and Bilateral Procedures Policies for Procedure Codes with Bilateral Surgery Indicator of 2

UnitedHealthcare Community Plan

• Outpatient Injectable Chemotherapy Prior Authorization Program for UnitedHealthcare Community Plan in Delaware, New Jersey, New York, Pennsylvania and Texas

• UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates

UnitedHealthcare Medicare Solutions

• UnitedHealthcare Medicare Advantage Coverage Summary Updates

Doing Business Better

• Virtual Card Payment Option Added to Electronic Payments and Statements

• Appropriate Diagnosis of Attention-Deficit/Hyperactivity Disorder

• Clinical Criteria for Determining Coverage

• Medical Records Standards

• Treatment for Members with Substance Use Disorder

UnitedHealthcare Affiliates

• Addition to Preferred Care Partners and Medica Provider Manuals

• Oxford® Medical and Administrative Policy Updates

• SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

• SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Updates

Network Bulletin: November 2013 - Volume 5833 For more information, call 877.842.3210

or visit UnitedHealthcareOnline.comNetwork Bulletin: November 2016

Front & Center

eligibilityLink and claimsLink Rollout Continues

We are introducing new and updated applications on Link – your gateway to UnitedHealthcare’s online tools and resources. The eligibilityLink and claimsLink applications are built with newer technology and offer enhanced design and features to help make the user experience more intuitive and time-saving — all based on care provider feedback.

These new applications will not launch to all UnitedHealthcareOnline.com users at the same time. Please watch your email inbox as the phased rollout of eligibilityLink and claimsLink continues. We will send you an email with information about webinar training sessions when you have access to the new applications.

When the new applications are available to you and you use Eligibility & Benefits, Claim Status or Claim Reconsideration on UnitedHealthcareOnline.com, you will see a pop-up box inviting you to try the new Link applications. You will have the opportunity to explore eligibilityLink and claimsLink before the corresponding Eligibility & Benefits, Claim Status and Claim Reconsideration functions are removed from UnitedHealthcareOnline.com.

The original Eligibility & Benefits, Claims Management and Claims Reconsideration applications on Link have some popular features that are not yet built into eligibilityLink and claimsLink, so we will continue to have both sets of applications into 2017. We are working to add new enhancements that will match and go beyond the functions on the original Link applications. Once that happens, the Eligibility & Benefits, Claims Management and Claims Reconsideration applications will be retired.

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The following chart shows the key differences between UnitedHealthcareOnline.com and the original and new Link applications:

Eligibility and Benefits Function UnitedHealthcareOnline.com Eligibility &

Benefits appeligibilityLink app

Provider Network Status for Member No Yes Coming Soon

Member ID Cards Yes Yes Yes

Care Opportunities Yes Yes Yes

View Previous Plans up to 18 months in the past

No No Yes

Therapy Accumulators (PT, OT, ST, etc.)

No No Coming Soon

Claims Management Function

UnitedHealthcareOnline.comClaims Management app

claimsLink app

Reimbursement Policy Applied No Yes Yes

Submit Claims Reconsideration Requests with Attachments

No Yes Yes

Pended/Closed Claim Attachments No Yes Yes

Electronic Submission of Appeals

No Yes Coming Soon

Electronic Corrected Claims No No Coming Soon

If you have questions, please call the UnitedHealthcare Connectivity Help Desk at 866-842-3278, option 3, 7 a.m. – 9 p.m. Central Time, Monday through Friday.

eligibilityLink and claimsLink Rollout Continues



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The Centers for Medicare & Medicaid Services (CMS) announced in CMS Transmittal 3578 dated Aug. 5, 2016 that effective for dates of service on or after Jan. 1, 2017, the Multiple Procedure Payment Reduction (MPPR) for the Professional Component (PC) of the second and subsequent procedures would change from 25 percent to 5 percent. This change applies to UnitedHealthcare Commercial and UnitedHealthcare Medicare Advantage plans.

To view the CMS transmittal, please visit cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R3578CP.pdf.

To align with CMS, UnitedHealthcare will revise the MPPR for Diagnostic Imaging Policy by applying a PC reduction to secondary and subsequent diagnostic imaging procedures of 5 percent effective for claims reported with a date of service on or after Jan. 1, 2017. To be consistent with CMS, the MPPR on the technical component (TC) of diagnostic imaging procedures remains at 50 percent.

Front & Center

Revisions to the Multiple Procedure Payment Reduction (MPPR) for Diagnostic Imaging Policy — Professional Component Reduction Change

Important Changes to Our Network of Durable Medical Equipment Providers

United Seating and Mobility dba Numotion has joined our national durable medical equipment (DME) network for Complex Rehab Technology (CRT) for all lines of business, effective Oct. 1 2016. CRT consists of customized configured wheelchairs, adaptive seating, positioning systems and other mobility devices designed to meet an individual’s specific medical, physical and functional needs to obtain mobility and independence. For more information, please contact Numotion at 888-232-1333 or numotion.com.

Effective Jan. 1, 2017, Wheelchair Professionals will no longer be a participating provider for CRT for all lines of business. Members who have out-of-network benefits provided by an out-of-network provider may incur increased financial liability and be exposed to higher out-of-pocket expenses. Please refer your patients to in-network facilities, including DME providers, as outlined in your network participation agreement. Visit myuhc.com for a complete list of UnitedHealthcare local or national DME providers for CRT.



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UnitedHealthcare understands the importance to care providers of obtaining eligibility and benefits information on our members who are your patients. Based on an internal system analysis, we believe you can get better results with your 270/271 Health Care Eligibility and Benefit Inquiry and Response transactions.

Our current search logic allows you to enter minimal information related to the member for the eligibility and benefits inquiry transaction (270). If we cannot locate a member, you may receive the following errors on an eligibility and benefits response transaction (271):

• AAA*Y*72 - Missing/Invalid Insured ID

• AAA*Y**73*C~AAA*Y**71*C - Invalid/Missing Name and Date of Birth

To help ensure we are returning eligibility and benefits information for all our members, UnitedHealthcare is recommending that you include the following information in the 270 inquiry transaction:

• Member ID

• Last Name

• First Name

• Patient Date of Birth

• Group Number (optional but recommended)

Using all of this information will lead to greater success in identifying members from our sources of eligibility. If you have any questions, please contact EDI Support:

UnitedHealthcare Commercial UnitedHealthcare Medicare SolutionsUnitedHealthcare OxfordUnitedHealthcare West

EDI issue reporting form or 800-842-1109

UnitedHealthcare Community Plan EDI issue reporting form or [email protected] or 800-210-8315

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Get Better Results for 270/271 Eligibility and Benefits Transactions

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Effective Dec. 1, 2016, the medical benefit agreement with Caremark Home Infusion and Specialty Pharmacy will be modified to remove certain drugs from Caremark’s Medical Benefit Agreement.

With this change effective Dec. 1, 2016, Caremark Home Infusion and Specialty Pharmacy will no longer be contracted to provide the following drugs under the medical benefit for home infusion services and some of the specialty products you may be using for your patients who are UnitedHealthcare members. (However, specialty products provided by Caremark Home Infusion and Specialty Pharmacy under our members’ pharmacy benefits will not be affected.)

Procedure Code Brand Name

J1931 Aldurazyme

J1786 Cerezyme

J0717 Cimzia

J0180 Fabrazyme

J1557 Gammaplex

J9351/J8705 Hycamtin

Q9979/J0202 Lemtrada

J0475 Lioresal Intrathecal

J0221 Lumizyme

J1725 Makena

J9306 Perjeta

J3490/J1602 Simponi

J3490 Solesta

J1300 Soliris (Phn-Soliris 10 Mg/Ml Soln)

J9226 Supprelin LA (Endo-Supprelin La 50 Mg Kit)

J7181 Tretten

J3385 VPRIV

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Effective Dec. 1, 2016, please refer affected members to an in-network vendor. Recommended in-network vendors that may be utilized, depending on drug therapy, include:

Home Infusion/Specialty Pharmacy Vendor Website Phone Number

AxelaCare axelacare.com 877-306-4036

BriovaRX briovarx.com 866-218-7398

BioScrip bioscrip.com 866-788-7710

Option Care optioncare.com 866-827-8203

Accredo accredo.com 800-803-2523

Change to Caremark Home Infusion and Specialty Pharmacy Medical Benefit Agreement

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Effective Jan. 1, 2017 UnitedHealthcare Community Plan will begin to serve eligible members in a new Dual Special Needs Plan (DSNP) – UnitedHealthcare Dual Complete – in the following five states and areas:

• Delaware - New Castle County

• Kansas - Johnson, Sedgwick, Wyandotte counties

• Louisiana - Jefferson, Lafourche, Orleans, St. Bernard and St. Charles parishes

• Mississippi – DeSoto and Hinds counties

• Rhode Island - Bristol, Kent, Newport, Providence and Washington counties

This is a Medicare Advantage plan for members who qualify for both Medicare and Medicaid. DSNPs are a specialized type of Medicare Advantage Prescription Drug Plan (MAPD) and must follow existing Centers for Medicare & Medicaid Services rules. DSNPs must:

• Adhere to required MAPD benefits

• Limit enrollment to Medicaid recipients (dually eligible – Medicare and Medicaid)

• Provide Part D benefits

• Offer targeted clinical programs, benefits and services.

UnitedHealthcare Community Plan will host training sessions to help ensure that network care providers understand how the plan works. For more information, visit UHCCommunityPlan.com > Health Care Professionals > Select your state > Dual Complete Program, or contact your network account manager or advocate.

New Dual Special Needs Program Will Launch in January 2017

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UnitedHealthcare has made a change to its prior authorization requirement for certain functional endoscopic sinus surgery procedures, which we implemented on May 2, 2016. CPT Code 31237 is no longer included in the requirement.

The following procedures will continue to require notification/prior authorization for many UnitedHealthcare Commercial and UnitedHealthcare Community Plan members in all states:

Procedures CPT Codes

Nasal/sinus endoscopy, surgical 31239 31240 31254 31255

31256 31267 31276 31287

31288

For more details, go to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Prior Authorization for Functional Endoscopic Sinus Surgery FAQ.

Update to Prior Authorization Requirement for Functional Endoscopic Sinus Surgery

Changes in Advance Notification and Prior Authorization Requirements

As announced in the June and September 2016 Network Bulletins, the Service Category-Home Health experienced procedure code removals from the prior authorization requirements for all UnitedHealthcare Medicare Solutions (including UnitedHealthcare West, Care Improvement Plus, Preferred Care Partners, United Healthcare Community Plan Medicare Advantage, UnitedHealth Care Connected plans (MMP).

As a result, the prior authorization requirements will continue for home health aide codes S9122 and G0156. To appropriately process the request for these services, documentation to support the need for skilled services is required. Please provide supporting documentation when requesting prior authorization for these two codes.

The timeframe when prior authorization is to be required has not changed.

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Each year UnitedHealthcare provides Special Needs Plan (SNP) Model of Care training required by the Centers for Medicare & Medicaid Services (CMS) for all our SNP network care providers. Please complete this year’s training by Dec. 16, 2016.

Go to UnitedHealthcareOnline.com > Tools & Resources > Training & Education > Medicare & Medicaid Topics. Click 2016 Special Needs Plan Model of Care Training to register or to read an FAQ about which care providers need to take the training.

If you have questions about whether you are required to take the Model of Care training or if you treat members in Special Needs Plans, please call 888-878-5499 or email us at [email protected].

Reminder: Please Complete CMS-required Model of Care Training

Communication Effectiveness Survey

We understand the volume of communications you receive from payers on a wide variety of topics and want to do whatever we can to streamline those you receive from UnitedHealthcare as well as improve those we do send. Please take a few moments to answer our brief three-question survey so we can continue to improve our communications to you. The survey is available online at uhcresearch.az1.qualtrics.com/jfe/form/SV_a2TkHLsEbvfxGgB. Thank you!



UnitedHealthcare CommercialNo Changes to Prior Authorization Process for Proton Beam Therapy

UnitedHealthcare requires care providers to obtain prior authorization for proton beam therapy for UnitedHealthcare Commercial members. Earlier this year, we announced a potential change to the prior authorization process would take effect during the fourth quarter of 2016. At this time, we have determined there will be no change to the prior authorization process for proton beam therapy. Care providers should continue to use the current process for prior authorization for proton beam therapy for UnitedHealthcare Commercial members.

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For complete details on the policy updates listed in the following table, please refer to the October 2016 Medical Policy Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletin.

Policy Title Policy Type Effective Date

NEW

Gender Dysphoria Treatment Medical Jan. 1, 2017

Percutaneous Vertebroplasty and Kyphoplasty Medical Dec. 1, 2016

Ocrevus® (Ocrelizumab) Drug Jan. 1, 2017

Probuphine® (Buprenorphine) Drug Jan. 1, 2017

Respiratory Interleukins (IL) Drug Jan. 1, 2017

Infertility Services CDG Dec. 1, 2016

UPDATED/REVISED

Attended Polysomnography for Evaluation of Sleep Disorders Medical Dec. 1, 2016

Autologous Chondrocyte Transplantation in the Knee Medical Oct. 1, 2016

Botulinum Toxins A and B Drug Oct. 1, 2016

Chemosensitivity and Chemoresistance Assays in Cancer Medical Nov. 1, 2016

Chromosome Microarray Testing Medical Oct. 1, 2016

Computed Tomographic Colonography Medical Oct. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Nov. 1, 2016

Gender Dysphoria (Gender Identity Disorder) Treatment CDG Oct. 1, 2016

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Medical Nov. 1, 2016

Gonadotropin Releasing Hormone Analogs Drug Jan. 1, 2017

Habilitative Services for Essential Health Groups CDGOct. 1, 2016

Jan. 1, 2017

Hepatitis Screening Medical Oct. 1, 2016

Home Health Care CDG Oct. 1, 2016

Hospital Readmissions QOC Oct. 1, 2016

UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates

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Immune Globulin (IVIG and SCIG) Drug Oct. 1, 2016

Infliximab (Remicade® and Inflectra™) Drug Nov. 1, 2016

Lyme Disease Medical Oct. 1, 2016

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Medical Nov. 1, 2016

Neurophysiologic Testing Medical Nov. 1, 2016

Omnibus Codes Medical Dec. 1, 2016

Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors Drug Oct. 1, 2016

Osteochondral Grafting of Knee Medical Oct. 1, 2016

Panniculectomy and Body Contouring Procedures CDG Nov. 1, 2016

Preventive Care Services CDG Oct. 1, 2016

Sensory Integration Therapy and Auditory Integration Training Medical Oct. 1, 2016

Sodium Hyaluronate Medical Oct. 1, 2016

Specialty Medication Administration – Site of Care Review Guidelines URG Nov. 1, 2016

Standing Systems and Gait Trainers Medical Nov. 1, 2016

Synagis® (Palivizumab) Drug Oct. 1, 2016

Virtual Upper Gastrointestinal Endoscopy Medical Oct. 1, 2016

Visual Information Processing Evaluation and Orthoptic and Vision Therapy Medical Oct. 1, 2016

Warming Therapy and Ultrasound Therapy for Wounds Medical Oct. 1, 2016

UPDATED/REVISED

Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting

Medical Oct. 1, 2016

Gender Dysphoria (Gender Identity Disorder) Treatment CDG Jan. 1, 2017

Note: The inclusion of a service or procedure on this list does not imply UnitedHealthcare provides coverage for the service or procedure. In the event of an inconsistency between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

UnitedHealthcare Medical Policy, Drug Policy and Coverage Determination Guideline Updates

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In November, please watch for the arrival of your new Premium designation assessment results.

Physicians who are in geographic areas where the UnitedHealth Premium designation program is available and practice in one of the Premium-eligible medical specialties will soon receive their Premium designation. The physician notification letter includes your Premium designation along with instructions on how to access your Premium assessment reports. Practice administrators for these physicians will also receive a group-level assessment letter that includes summary information by medical specialty.

Please go to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium to review the 2017 Methodology, FAQ and other Premium resources. Designations will be publicly displayed on Jan. 4, 2017.

Reconsideration Prior to public display of your designation, we will provide time for you to review your assessment reports and request reconsideration, if applicable. Submit your request on or before Dec. 5, 2016 so we can make any applicable changes to your designation before it is publicly displayed. We continue to accept and review requests after this date and will make any applicable change to your publicly-displayed designation.

Enhancements and Updates for 2017

Premium Methodology Updates:

• New time frame for claims data: Jan. 1, 2013 – March 31, 2016.

• Updated measures using Symmetry version 9 tools: this uses the most up-to-date evidenced-based measures to assess quality.

• Use of specialty-specific quality benchmarks: this provides for a comparison of physicians with the same specialty rather than comparing all physicians who may treat patients with the same conditions.

• Updated geographic area based on Core Based Statistical Areas (CBSA) defined markets: this better reflects consumer selection practices due to the CBSA’s high degree of social and economic integration as measured through commuting ties with the CBSA.

• Narrowed list of conditions included for Patient Total Cost assessment: this includes only those patients’ costs that are more directly under the physician’s control.

Simplified Methodology Design through use of Modules We redesigned the UnitedHealth Premium methodology document to provide an adaptable and self-paced learning tool. The methodology is transparent and easy to follow. The main body of the methodology provides a simplified design for those who want a straightforward overview of the Premium methodology. In addition the methodology includes multiple links to subject-specific modules that provide an in-depth explanation about important components of the program. You will find a more detailed level of information about topics such as attribution, statistical tests and examples of quality and cost efficiency assessment processes.

UnitedHealth Premium® Designation Program – 2017 Designations

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Please review the Premium program’s updated UnitedHealth Premium Methodology located at UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium.

New Designations for 2017 The Premium program will use the following new icons to indicate the Premium designations of physicians in provider directories:

Premium Care Physician

Quality Care Physician

Quality Not Evaluated

Does not Meet Quality

Ophthalmology Update: Beginning Jan. 4, 2017, ophthalmology is no longer included in the Premium program due to the limited number of ophthalmologists that can be assessed. Based on the latest quality measures and data available to evaluate this specialty, the majority of ophthalmologists did not have enough data to assess their performance in the Premium program.

For more information about the Premium program, please sign in to UnitedHealthcareOnline.com > Quick Links > UnitedHealth Premium or call us at 866-270-5588.

UnitedHealth Premium® Designation Program – 2017 Designations

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UnitedHealthcare Commercial Reimbursement PoliciesUnless otherwise noted, the following reimbursement policies apply to services reported using the 1500 Health Insurance Claim Form (CMS-1500) or its electronic equivalent or its successor form. UnitedHealthcare reimbursement policies do not address all factors that affect reimbursement for services rendered to UnitedHealthcare members, including legislative mandates, member benefit coverage documents, UnitedHealthcare medical or drug policies, and the UnitedHealthcare Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented, the policies may be viewed in their entirety at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Reimbursement Policies-Commercial. In the event of an inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails.

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UnitedHealthcare Commercial Reimbursement Policies



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UnitedHealthcare’s Maximum Frequency per Day (MFD) and Bilateral Procedures policies consider bilateral payment through the use of modifiers LT and RT as inappropriate for procedures, services and supplies where the concept of laterality does not apply. These policies allow payment up to the maximum frequency per day value for codes with “bilateral” or “unilateral or bilateral” in their description or for codes where the concept of laterality does not apply, whether submitted with or without modifiers LT and/or RT by the same individual physician or other health care professional on the same date of service for the same member.

Many of the codes whose descriptions have “bilateral” or “unilateral or bilateral” in their description also have a Centers for Medicare & Medicaid Services (CMS) National Physician Fee Schedule Bilateral Surgery indicator of 2, which is defined by CMS as, “150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure.” In addition, some of the codes with a CMS Bilateral Surgery indicator of 2 do not have “bilateral” or “unilateral or bilateral” verbiage in their description, but they are also not eligible for bilateral reimbursement.

Effective for claims processed in the first quarter of 2017, UnitedHealthcare will no longer allow the Bilateral Surgery indicator 2 codes to be reimbursed for two sides when billed with modifiers LT and RT. While this concept applies to both the Bilateral Procedures and MFD policies, the MFD policy contains the complete list of codes for which the concept of laterality does not apply. This list includes all codes that have “bilateral” or “unilateral or bilateral” in their description and will also include all Bilateral Surgery indicator 2 codes.

Revision to Maximum Frequency per Day and Bilateral Procedures Policies for Procedure Codes with Bilateral Surgery Indicator of 2




Outpatient Injectable Chemotherapy Prior Authorization Program for UnitedHealthcare Community Plan in Delaware, New Jersey, New York, Pennsylvania and Texas

Effective Jan. 1, 2017, UnitedHealthcare Community Plan members in Delaware, New Jersey, New York, Pennsylvania and Texas will require prior authorization for injectable outpatient chemotherapy drugs given for a cancer diagnosis.

This requirement has been in place for UnitedHealthcare’s Commercial members since June 1, 2015.

Prior authorization will be required for:

• Chemotherapy injectable drugs (J9000 - J9999), Leucovorin (J0640) and Levoleucovorin (J0641)

• Chemotherapy injectable drugs that have a Q code

• Chemotherapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS)

• All outpatient injectable chemotherapy drugs started after the chemotherapy prior authorization effective date

• Adding a new injectable chemotherapy drug to a regimen

If a UnitedHealthcare Community Plan member in New Jersey, New York, Texas, Delaware or Pennsylvania received injectable chemotherapy drugs in an outpatient setting Oct. 1, 2016 through Dec. 31, 2016, you do not need to submit a prior authorization request until a new chemotherapy drug will be administered. We will authorize the chemotherapy regimen the member was receiving prior to Jan. 1, 2017 and the authorization will be effective until Dec. 31, 2017.

To complete a prior authorization request, go to UnitedHealthcareOnline.com > Notifications/Prior Authorizations > Oncology Authorizations Submission & Status. For more information or to request prior authorization by phone, call 866-889-8054.

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UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the October 2016 Medical Policy Update Bulletin at UHCCommunityPlan.com > For Health Care Professionals > Select Your State > Provider Information > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines.


NEW

Gender Dysphoria Treatment Medical Jan. 1, 2017

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Medical Nov. 1, 2016

Attended Polysomnography for Evaluation of Sleep Disorders Medical Dec. 1, 2016

Autologous Chondrocyte Transplantation In The Knee Medical Oct. 1, 2016

Bone or Soft Tissue Healing and Fusion Enhancement Products Medical Nov. 1, 2016

Chemosensitivity and Chemoresistance Assays in Cancer Medical Dec. 1, 2016

Chromosome Microarray Testing Medical Oct. 1, 2016

Computed Tomographic Colonography Medical Oct. 1, 2016

Core Decompression for Avascular Necrosis Medical Nov. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Medical Nov. 1, 2016

Functional Endoscopic Sinus Surgery (FESS) Medical Nov. 1, 2016

Gender Dysphoria (Gender Identity Disorder) Treatment CDG Oct. 1, 2016

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndrome (HBOC) Medical Dec. 1, 2016

Hepatitis Screening Medical Oct. 1, 2016

Home Health Care CDG Oct. 1, 2016

Lyme Disease Medical Oct. 1, 2016

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Medical Dec. 1, 2016

Neurophysiologic Testing Medical Dec. 1, 2016

Omnibus Codes MedicalNov. 1, 2016

Dec. 1, 2016

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Orthognathic (Jaw) Surgery CDG Nov. 1, 2016

Osteochondral Grafting of Knee Medical Oct. 1, 2016

Panniculectomy and Body Contouring Procedures CDG Nov. 1, 2016

Sensory Integration Therapy and Auditory Integration Training Medical Oct. 1, 2016

Sodium Hyaluronate Medical Oct. 1, 2016

Standing Systems and Gait Trainers Medical Dec. 1, 2016

Total Artificial Heart Medical Nov. 1, 2016

Virtual Upper Gastrointestinal Endoscopy Medical Oct. 1, 2016

Visual Information Processing Evaluation and Orthoptic and Vision Therapy Medical Oct. 1, 2016

Warming Therapy and Ultrasound Therapy for Wounds Medical Oct. 1, 2016

RETIRED/REPLACED

Gender Dysphoria (Gender Identity Disorder) Treatment CDG Jan. 1, 2017

Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting

Medical Oct. 1, 2016


UnitedHealthcare Community Plan Medical Policy & Coverage Determination Guideline Updates

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UnitedHealthcare Medicare Solutions

UnitedHealthcare Medicare Advantage Coverage Summary Updates

For complete details on the policy updates listed in the following table, please refer to the October 2016 Medicare Advantage Coverage Summary Update Bulletin at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > UnitedHealthcare Medicare Advantage Coverage Summaries > Update Bulletin.

Policy Title

UPDATED/REVISED (Approved on Sept. 20, 2016)

Allergy Testing and Allergy Immunotherapy

Cosmetic and Reconstructive Procedures

Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid

Orthopedic Procedures, Devices and Products

Pain Management and Pain Rehabilitation

Renal Services and Procedures

Shoes and Foot Orthotics

Sleep Apnea: Diagnosis and Treatment

Stimulators: Electrical and Spinal Cord Stimulators

Stimulators: Osteogenic Stimulators

Transplants: Organ and Tissue Transplants

Uterine Services and Procedures

Varicose Veins Treatment and Other Vein Embolization Procedures


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Virtual Card Payment Option Added to Electronic Payments and Statements

Optum’s Electronic Payments and Statements (EPS) previously offered electronic funds transfer (EFT) by direct deposit and electronic remittance advice (ERA). Now, you can choose between direct deposit and Virtual Card Payments (VCP) for UnitedHealthcare Commercial, UnitedHealthcare Medicare Advantage and UnitedHealthcare Community Plan.

VCP offers a secure electronic payment method that uses credit card-based payment technology. After enrollment, you’ll receive a mailer with a card number for your first payment (actual cards are not issued). For all subsequent payments, you’ll receive an email notification only and you can process your payment with the same card number.

Payment PostingOnce enrolled, you’ll no longer receive paper electronic remittance advices and can access your information on the EPS website or enroll to receive 835 files. You can view a video to see how the website works or register for an instructor-led webcast session. More information about payment posting is also available on WelcometoEPS.com.

Benefits of VCPUnlike direct deposit, there is no requirement to share your bank account information to receive VCP. Your practice can receive electronic payments using your existing payment card terminal, receiving payment five to seven days sooner than traditional check payments.

Minimal RequirementsYou must have a credit card machine to process VCP, but there is no special software or training needed. For accessing your remittance advice on EPS, you need an internet connection.

UnitedHealthcare does not charge fees for VCP. However, your credit card processing fees will apply. Please confirm those rates with your merchant processor.

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Virtual Card Payment Option Added to Electronic Payments and Statements

VCP Compared to Direct Deposit

Direct Deposit/Automated Clearinghouse (ACH) VCP

Process:1. Enroll in EPS online with ACH selection.2. Receive email notifications when payments

are deposited.3. 835/ERA available the same day for auto-

posting, or save, view or print remittance advice and post payments manually from Optum’s EPS website.

Considerations:• Receive payments and remittances five to

seven days faster than with paper• No credit card processing fees from your

merchant processor• Reduced risk of lost, misrouted and stolen

checks• Potential elimination of bank lock box fees• Money is deposited directly into the

account(s) you designate • Payments and remittances can be separated

by NPI and/or payer

Process:1. Enroll in EPS online with VCP selection. 2. Receive a card number(s) in the mail with

activation instructions (future payment notices delivered by email). Redeem payment using the standard “card not present” transaction

3. 835/ERA available the same day for auto-posting, or save, view or print remittance advice and post payments manually from Optum’s EPS website.

Considerations:• Receive payments and remittances five to

seven days faster than with paper• Credit card processing fees apply (confirm

with merchant processor)• Reduced risk of lost, misrouted and stolen

checks• Potential elimination of bank lock box fees• You will receive a separate card number for

each UnitedHealthcare payer that provides payments

• Please allow seven to 10 business days after the first payment is available on the website to receive your virtual card number in the mail.

For more information, please visit UnitedHealthcareOnline.com > Quick Links > Electronic Payments and Statements. You can call 877-620-6194 to speak with an EPS representative.

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Appropriate Diagnosis of Attention-Deficit/ Hyperactivity Disorder

Appropriate diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD) requires a comprehensive medical evaluation to rule out potential medical causes of the symptoms.

The accuracy of diagnosing improves when appropriate clinical practice guidelines are used and when history is collected from both parents and teachers. Both the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry (AACAP) have developed evidence based clinical practice guidelines. Once diagnosis is confirmed, the treatment plan usually includes a combination of behavior modification, pharmacotherapy parent training and education. UBH offers educational materials for patients on a variety of behavioral health topics including ADHD at liveandworkwell.com > health and wellbeing > conditions by name. Your patients can log on using the access code “united.”

The National Committee for Quality Assurance uses Healthcare Effectiveness Data and Information Set (HEDIS®) data to assess the frequency of follow-up visits for children undergoing pharmacotherapy for ADHD. While some patients require more frequent monitoring, the minimum follow-up required based on HEDIS measures is:*

• When children ages 6-12 start medication for ADHD, they should receive a follow-up visit within 30 days of the initial treatment.

• Those same children should be seen for at least two additional follow-up visits within the initial nine months of starting treatment.

*HEDIS 2016: Specifications for Survey Measures

Clinical Criteria for Determining Coverage

UnitedHealthcare and its affiliated health plans use medical policies sourced to peer-reviewed medical literature, internally developed coverage determination guidelines (CDGs) and nationally recognized clinical practice guidelines, including MCG (formerly Milliman Care Guidelines) for clinical reviews. For our Medicare Advantage plans, UnitedHealthcare also reviews the Centers for Medicare & Medicaid Services (CMS) guidance, including CMS manuals, National Coverage Determinations (NCDs), Local Coverage Determinations (LCDs) (the written coverage decisions of local Medicare contractors), and where no NCDs or LCDs exist, evidence-based medical policies and clinical guidelines.

Changes to medical policies and coverage determination guidelines are routinely communicated in the Network Bulletin. Medical policies and coverage determination guidelines used to determine coverage of a particular medical procedure or treatment are available online or by calling the phone numbers listed on the member ID card. Our medical directors are also available to discuss the criteria and their decisions with you.




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Medical Records Standards

A comprehensive, detailed medical record is key to promoting quality medical care and improving patient safety.

UnitedHealthcare recommends that you have signed, written policies to include:

1. Maintenance of a single, permanent medical record that is current, organized and comprehensive for each patient and available at each visit.

2. Protection of patient records against loss, destruction, tampering or unauthorized use. This includes having adequate security safeguards in electronic medical records to prevent unauthorized access or alteration of records. Such safeguards must not be able to be overridden or turned off.

3. Periodic staff training regarding confidentiality.

4. Records storage to ensure privacy and security while allowing easy retrieval by authorized persons.

5. Mechanisms for monitoring and handling missed appointments.

We also expect you to follow these commonly accepted guidelines for medical record information and documentation:

• Include patient’s identifying information on each page.

• Ensure that records reflect all services provided, ancillary services/tests ordered, and all diagnostic/therapeutic services referred by the physician/health care professional. This includes hospital discharge summaries and consultations from other physicians/health care professionals.

• Document physician review of all labs, x-rays, consultation reports, behavioral health reports, ancillary providers’ reports, hospital records and outpatient records.

• Make it easy to identify the medical history, and include chronic illnesses, accidents, operations, family and social history: cite medical conditions and significant illnesses on a problem list and document clinical findings and evaluation for each visit.

• Include evidence of periodic depression screening.

• Include documentation of smoking, ETOH and substance use/abuse history beginning at age 11.

• For medication record, include name of medication and dosages. Also, list over-the-counter drugs taken by the member.

• Give prominence to notes on allergies and adverse reactions or note that the member has no known allergies or adverse reactions.

• Date all entries, and identify the authors. Documentation of records generated by word processing software or electronic medical records software should include all authors and their credentials. It should also be apparent from the documentation which individual performed a given service.

• Clearly label additions or corrections to a medical record entry with the author and date of change and maintain the original entry.

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Medical Records Standards

• Generate documentation at the time of service or shortly thereafter.

• Clearly label any documentation generated at a previous visit as previously obtained, if it is included in the current record.

• Prominently display information on advance directives.

Documentation that is not reasonable and necessary for the diagnosis or treatment of an injury or illness or to improve the function of a malformed body member should not be considered when selecting the appropriate level of an E&M service. Only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate E&M level.

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Treatment for Members with Substance Use Disorder

Substance use disorder is a national problem. According to the Substance Abuse and Mental Health Services Administration, 7.6 percent of the U.S. population ages 12 and older had a substance use disorder due to alcohol dependence or abuse, and 14.6 percent had a substance use disorder due to illicit drug dependence or abuse in 2014. Of the 24.1 million Americans who needed specialized treatment for a drug or alcohol problem, almost 22 million did not receive it, the government agency said. Improving the treatment afforded to individuals who are diagnosed with substance use disorder helps reduce drug-related illnesses and deaths, overuse of health care services, and the staggering economic and interpersonal burdens associated with substance abuse.

The first step is to properly identify a substance use disorder. There are several brief and easy-to-administer assessment tools available to help screen patients with potential substance use disorders, including: AUDIT-C, CAGE, CAGE-AID and CRAFFT. These screening tools can be accessed at providerexpress.com under Clinical Resources in the Optum Forms – Clinical section.

Once a patient is diagnosed with a substance use disorder, it’s important they get treatment right away. According to Healthcare Effectiveness Data and Information Set (HEDIS®) standards, individuals who are newly diagnosed should be seen for a follow-up appointment at least within 14 days and then again two more times within 30 days.

No single treatment is appropriate for all individuals. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Identify and involve concerned others to increase the rate of participation in treatment. Welcome calls from family members and other people with whom the patient approves to support their care. Invite support persons’ help in intervening with the patient diagnosed with a substance use disorder.

More information on substance use disorders and patient resources is available at providerexpress.com under “Clinical Resources - LiveandWorkWell (LAWW) clinician center – Be Well – Addictions.”



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Addition to Preferred Care Partners and Medica Provider Manuals

UnitedHealthcare is providing the following information that should be considered as part of the Preferred Care Partners and Medica provider manuals:

Medicare Compliance Expectations and TrainingAs part of an effective Compliance Program, CMS requires Medicare Advantage (MA) organizations and Part D plan sponsors, including UnitedHealthcare and its affiliates, (i.e., Preferred Care Partners and Medica health insurance plans), to annually communicate specific Compliance and Fraud, Waste and Abuse (FWA) requirements to their “first tier, downstream, and related entities” (FDRs). These include contracted physicians, health care professionals, facilities and ancillary care providers, as well as delegates, contractors, and related parties.

The required education, training and screening to which we – and you – are subject to include, but are not limited to, the following:

1) Standards of Conduct AwarenessFDRs working on Medicare Advantage and Part D programs – including contracted care providers – must provide a copy of their own or UnitedHealth Group’s (UHG’s) Code of Conduct at unitedhealthgroup.com > About > Ethics & Integrity > UnitedHealth Group’s Code of Conduct (PDF file) to their employees (including temporary workers and volunteers), the CEO, senior administrators or managers, governing body and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA or Part D benefits or services within 90 days of hire and annually thereafter (by the end of the year).

What You Need to Do for Standards of Conduct Awareness: Provide your own or UHG’s Code of Conduct as outlined above and maintain records of distribution standards (i.e. in an email, website portal or contract, etc.) for 10 years. Documentation may be requested by UnitedHealthcare or CMS to verify compliance with this requirement.

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2) Monthly Federal/State Exclusion Check

Exclusion ChecksFDRs must review federal exclusion lists (HHS-OIG and GSA) and state exclusion lists, as applicable, prior to hiring/contracting with employees (including temporary workers and volunteers), the CEO, senior administrators or managers, and sub delegates who have involvement in or responsibility for the administration or delivery of UnitedHealthcare MA and Part D benefits or services to make sure that none are excluded from participating in Federal health care programs.

FDRs must continue to review the federal and state exclusion lists on a monthly basis thereafter. For more information or access to the publicly accessible excluded party online databases, please see the following links:

• Health and Human Services – Office of the Inspector General OIG List of Excluded Individuals and Entities (LEIE) at oig.hhs.gov.

• General Services Administration (GSA) System for Award Management at SAM.gov

What You Need to Do for Exclusion Checks?Review applicable exclusion lists as outlined above and maintain a record of exclusion checks for 10 years. Documentation of the exclusion checks may be requested by UnitedHealthcare or CMS to verify that checks were completed.

If you identify compliance issues and/or potential fraud, waste, or abuse, please report it to us immediately so that we can investigate and respond appropriately. UnitedHealthcare expressly prohibits retaliation if a report is made in good faith.

Refer to the How to Contact Us section of your provider manual for contact information: Mypreferredcarepartners.com > Medicare > Provider Resources > Provider Manual Medicaplans.com > Physicians and Providers > Provider Manual.

Provider Administrative Guides supplement your provider contract and offer a single location where the majority of your day-to-day questions can be answered. Access the guides online at UnitedHealthcareOnline.com or UHCCommunityPlan.com.

Addition to Preferred Care Partners and Medica Provider Manuals

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Oxford® Medical and Administrative Policy Updates

For complete details on the policy updates listed in the following table, please refer to the October 2016 Policy Update Bulletin at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin.


NEW

Evaluation and Management (E/M) Reimbursement Nov. 1, 2016

Percutaneous Vertebroplasty and Kyphoplasty Clinical Dec. 1, 2016

Respiratory Interleukins (IL) Policy Clinical Jan. 1, 2017

Simponi® Aria™ (Golimumab) Injection for Intravenous Infusion Clinical Dec. 1, 2016

UPDATED/REVISED

Abnormal Uterine Bleeding and Uterine Fibroids Clinical Nov. 1, 2016

Abortions (Therapeutic and Elective) Administrative Oct. 1, 2016

Assignment of Benefits & Balance Billing Administrative Nov. 1, 2016

Behavioral Health Services Clinical Oct. 1, 2016

Bone or Soft Tissue Healing and Fusion Enhancement Products Clinical Nov. 1, 2016

Botulinum Toxins A and B Clinical Oct. 1, 2016

Chromosome Microarray Testing Clinical Oct. 1, 2016

Clotting Factors and Coagulant Blood Products Clinical Oct. 1, 2016

Contraceptives Clinical Oct. 1, 2016

Core Decompression for Avascular Necrosis Clinical Nov. 1, 2016

Drug Coverage Criteria - New and Therapeutic Equivalent Medications Clinical Nov. 1, 2016

Drug Coverage Guidelines Clinical Nov. 1, 2016

Emergency Room Visits (Including Coverage of Members Outside of the United States) Administrative Nov. 1, 2016

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Entyvio™ (Vedolizumab) Clinical Oct. 1, 2016

Epidural Steroid and Facet Injections for Spinal Pain Clinical Oct. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Clinical Nov. 1, 2016

Follicle Stimulating Hormone (FSH) Gonadotropins Clinical Nov. 1, 2016

Functional Endoscopic Sinus Surgery (FESS) Clinical Nov. 1, 2016

Gender Dysphoria (Gender Identity Disorder) Treatment Clinical Oct. 1, 2016

Gender Dysphoria Treatment Clinical Jan. 1, 2017

Gonadotropin Releasing Hormone Analogs Clinical Jan. 1, 2017

High Frequency Chest Wall Compression Devices Clinical

Oct. 1, 2016

Nov. 1, 2016

Home Health Care Clinical Oct. 1, 2016

Human Menopausal Gonadotropins (HMG) Clinical Nov. 1, 2016

Immune Globulin (IVIG and SCIG) Clinical Oct. 1, 2016

Infliximab (Remicade® and Inflectra™) Clinical Nov. 1, 2016

Lemtrada (Alemtuzumab) Clinical Oct. 1, 2016

Lithotripsy for Salivary Stones Clinical Oct. 1, 2016

Lupron-Depot/Lupron-Depot Ped (Leuprolide Acetate) Clinical Oct. 1, 2016

Manipulation Under Anesthesia Clinical Oct. 1, 2016

Maximum Frequency Per Day Reimbursement Oct. 1, 2016

Microsurgery Reimbursement Oct. 1, 2016

Modifier Reference Reimbursement Nov. 1, 2016

Multiple Procedures Reimbursement Dec. 1, 2016

Nerve Graft to Restore Erectile Function During Radical Prostatectomy Clinical Oct. 1, 2016

Neurophysiologic Testing Clinical Oct. 1, 2016

Nonphysician Health Care Codes Reimbursement Nov. 1, 2016

Nonphysician Health Care Professionals Billing Evaluation and Management Codes Reimbursement Oct. 1, 2016

Obstetrical Policy Reimbursement Oct. 1, 2016

Once in a Lifetime Procedures Reimbursement Nov. 1, 2016

Orthognathic (Jaw) Surgery Clinical Nov. 1, 2016

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Orthopedic Services Administrative Oct. 1, 2016

Otoacoustic Emissions Testing Clinical Oct. 1, 2016

Panniculectomy and Body Contouring Procedures Clinical Nov. 1, 2016

Plagiocephaly and Craniosynostosis Treatment Clinical Oct. 1, 2016

Precertification Exemptions for Outpatient Services Administrative Oct. 1, 2016

Preventive Care Services Clinical Oct. 1, 2016

Preventive Medicine and Screening Reimbursement Oct. 1, 2016

Prolonged Services Reimbursement Nov. 1, 2016

Prosthetic Devices, Wigs, Specialized, Microprocessor or Myoelectric Limbs Clinical Oct. 1, 2016

Radiology Procedures Requiring Precertification for eviCore healthcare Arrangement

Clinical Oct. 1, 2016

Remicade (Infliximab) Clinical Oct. 1, 2016

Routine Foot Care Clinical Oct. 1, 2016

Sandostatin Lar Depot (Octreotide Acetate) Clinical Oct. 1, 2016

Sodium Hyaluronate Clinical Oct. 1, 2016

Specialty Medication Administration - Site of Care Review Guidelines Clinical Nov. 1, 2016

Speech Therapy and Early Intervention Programs/Birth to Three Administrative Oct. 1, 2016

Synagis® (Palivizumab) Clinical Oct. 1, 2016

Total Artificial Heart Clinical Nov. 1, 2016

Unicondylar Spacer Devices for Treatment of Pain or Disability Clinical Oct. 1, 2016

Vision Services Administrative Oct. 1, 2016

Wrong Surgical or Other Invasive Procedures Reimbursement Oct. 1, 2016


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RETIRED

Assignment of Benefits to Non-Network Providers Administrative Nov. 1, 2016

Balance Billing Administrative Nov. 1, 2016

Complementary and Alternative Medicine (CAM) Contracted Rate Program Clinical Oct. 1, 2016

Emergency Room Visits Administrative Nov. 1, 2016

Members Outside of the United States Administrative Nov. 1, 2016

Presacral Neurectomy and Uterine Nerve Ablation for Pelvic Pain Clinical Oct. 1, 2016

Note: The inclusion of a service or procedure to this list does not imply that Oxford provides coverage for the service or procedure. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail.

Oxford HMO products are underwritten by Oxford Health Plans (NY), Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc.

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SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

For complete details on the policy updates listed in the following table, please refer to the October 2016 SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guidelines Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Title Effective Date

NEW

Gender Dysphoria Treatment Excluding California Jan. 1, 2017

UPDATED/REVISED

Autologous Chondrocyte Transplantation in the Knee Oct. 1, 2016

Chemosensitivity and Chemoresistance Assays in Cancer Nov. 1, 2016

Chromosome Microarray Testing Oct. 1, 2016

Computed Tomographic Colonography Oct. 1, 2016

Emergency Health Services and Urgent Care Center Services Nov. 1, 2016

Fetal Aneuploidy Testing Using Cell-Free Fetal Nucleic Acids in Maternal Blood Nov. 1, 2016

Genetic Testing for Hereditary Breast and/or Ovarian Cancer Syndromes (HBOC) Nov. 1, 2016

Hepatitis Screening Oct. 1, 2016

Lyme Disease Oct. 1, 2016

Manipulation Under Anesthesia Nov. 1, 2016

Minimally Invasive Procedures for Gastroesophageal Reflux Disease (GERD) Nov. 1, 2016

Neurophysiologic Testing Nov. 1, 2016

Orthognathic (Jaw) Surgery Nov. 1, 2016

Osteochondral Grafting of Knee Oct. 1, 2016

Otoacoustic Emissions Testing Oct. 1, 2016

Panniculectomy and Body Contouring Procedures Nov. 1, 2016

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SignatureValue/UnitedHealthcare Benefits Plan of California Medical Management Guideline Updates

Title Effective Date

Preventive Care Services Oct. 1, 2016

Sensory Integration Therapy and Auditory Integration Training Oct. 1, 2016

Sodium Hyaluronate Oct. 1, 2016

Specialty Medication Administration – Site of Care Review Guidelines Nov. 1, 2016

Standing Systems and Gait Trainers Nov. 1, 2016

Virtual Upper Gastrointestinal Endoscopy Oct. 1, 2016

Visual Information Processing Evaluation and Orthoptic and Vision Therapy Oct. 1, 2016

Warming Therapy and Ultrasound Therapy for Wounds Oct. 1, 2016

RETIRED

Transcutaneous Electrical Nerve Stimulation (TENS) for the Treatment of Nausea and Vomiting Oct. 1, 2016





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SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Updates

For complete details on the policy updates listed in the following table, please refer to the October 2016 SignatureValue/UnitedHealthcare Benefits Plan of California Benefit Interpretation Policy Update Bulletin at UHCWest.com > Provider Log In > Library > Resource Center > Guidelines & Interpretation Manuals.

Policy Title Applicable State(s) Effective Date

UPDATED/REVISED

BiofeedbackAll (California, Oklahoma, Oregon, Texas and Washington)

Nov. 1, 2016

Clinical Trials Nov. 1, 2016

Continuity of Care Nov. 1, 2016

Gender Dysphoria (Gender Identity Disorder) Treatment Oregon and Washington Jan. 1, 2017

Home Health Care

All

Nov. 1, 2016

Hospice Oct. 1, 2016

Immunizations/Vaccinations Nov. 1, 2016


Network Bulletin: November 2016Doc#: PCA-1-003772-10172016_10212016

Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc. OptumRx, OptumHealth Care Solutions, Inc. or its affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.

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