Tag: #UHC

Posted in #unitedhealthcare, Training, Updates

UHC: Genetic testing for hereditary cancer-11 codes that are not covered

Posted on by KR2Medical Billing

Ordering Genetic Testing for your patients? Avoid the costly and unnecessary denials with the most up to date medical coding and medical billing guideline information. Below please find the updated information regarding UHC Genetic testing for hereditary cancer information.

There are 11 codes that were added to the list of non-covered, experimental/investigational list.

These codes will be denied, no matter the prior authorization status, as the Genetic Testing for Hereditary Cancer medical policy states, “genetic testing for BRCA1 and BRCA2 or Multi-Gene hereditary panels with RNA testing is unproven.”

The changes are applied to both Commercial and Medicaid Plans.

UHC Commercial Medical Policy. To visit the full policy please click here.
UHC Community Health (Medicaid)Medical Policy. For the full medical policy, please click here.

Partial List of non covered codes:

For the full list of noncovered codes please click here.

This change does not affect other BRCA1 testing, BRCA2 testing or multi-gene hereditary cancer panels, which will continue to require prior authorization.

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Posted in #unitedhealthcare, Payer Updates, Training, Updates

UHC Community Health (Several States) anti-emetic prior authorization update

Posted on by KR2Medical Billing

This policy is effective Aug. 1, 2021, and applies to the following states, UHC Community Health Plan:

Arizona, Kentucky and Tennessee that require prior authorization for outpatient injectable chemotherapy.

There are 8 anti-emetic codes (see below) that will be added to the prior authorization list, for patients that have cancer diagnosis. (Prior authorization requirements for outpatient injectable chemotherapy are not affected by this addition.)

Providers can choose from the preferred products (see below):

Preferred products are Emend®, Kytril® and Zofran®. For more information about preferred products, see the medical policy listed below.

How to submit prior authorization:

If the member received anti-emetic drugs in an outpatient setting for a cancer diagnosis from May 1, 2021, through July 31, 2021, you DO NOT need to submit a prior authorization request until a new anti-emetic drug will be administered.

UHC Community Health Plan will authorize the anti-emetic drug the member was receiving prior to Aug. 1, 2021, and the authorization will be effective until Jan. 31, 2022, unless a change in treatment is needed.

Please complete all notifications online. Sign into the UnitedHealthcare Provider PortalOpens in a new windowopen_in_new using your One Healthcare ID and select the Prior Authorization and Notification tool. Once you are in the tool, select Oncology, and when prompted, answer the questions about the service type, member type and state. You can submit authorizations for anti-emetics on July 1, 2021, in advance of the Aug. 1, 2021, requirement.

Coverage determination guidelines

On July 1, 2021, the Medical Benefit Drug Policy titled Anti-Emetics for Oncology will be available at:

Prior to July 1, 2021, the policy can be accessed from:

#UHC, #UHCommunityhealth, #KYmedicaid, #AZmedicaid, #TNmedicaid, #aprepitant, #rolapitant, #netupitant, #cancer, #oncology

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Posted in #unitedhealthcare, Updates

How is UHC assessing ED facility commercial claims, 07/01/2021

Posted on by KR2Medical Billing

This policy will become effective as of 07/01/2021 and will apply to commercial claims for “most states”.

The claims will be assessed according to existing plan provisions and evaluated on, including:

  • The patient’s presenting problem
  • The intensity of diagnostic services performed
  • Other patient complicating factors and external causes

If the claims are determined to be non-emergent than the claim will not be paid or subject to limited coverage in accordance with the member’s Certificate of Coverage. 

This enhanced capability will apply to commercial fully insured ED facility claims in many states for dates of service on July 1, 2021, or later. Subject to regulatory approval we will continue to expand this capability to additional states and segments.   

Attestation:

If an ED event is determined to be non-emergent, you’ll have the opportunity to complete an attestation if the event met the definition of an emergency consistent with the prudent layperson standard. 

A notice of the opportunity to submit an attestation will be sent electronically to the facility when an ED event is determined to be non-emergent. Instructions about accessing the attestation through UHCprovider.com will be included. We may also follow up with a mailed letter about the attestation.

If the attestation is submitted within the required time frame, the claim will typically be processed according to the plan’s emergency benefits.

UnitedHealthcare reserves the right to order medical records for claims review, even if an attestation has been submitted.

If providers have any questions, please contact Provider Services at 877-842-3210 or your Network Representative.

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