Tag: #uhccommercial

Posted in #unitedhealthcare, Training, Updates

UHC Commercial Plan: new prenatal ultrasound policy -2022

Posted on by KR2Medical Billing

As of 06/01/2022- UHC announced a new prenatal ultrasound policy for the year 2022. The reimbursement for this policy will be determined post-service, with pre-pay based on the following:

  1. The first 3 prenatal ultrasounds are going to be covered and medical necessary: CPT® codes 76801, 76802, 76805, 76810, 76811, 76812, 76815, 76816 and 76817
  2. 4 or more ultrasounds will be considered proven and medically necessary for high-risk pregnancies, as described in the policy, when the treating provider will make therapeutic determinations based upon the results.

This policy applies towards professional services billed on HCFA1500 form and performed in POS 11 and 22.

This policy doesn’t apply to:

  • Prenatal ultrasounds rendered in an emergency room
  • Outpatient observation care
  • Inpatient hospital setting

Charging patients for NON-COVERED services:

Please note, you’ll need to get written consent prior to the service if you bill patients for services denied for lack of medical necessity. Patient consent will need an estimate of the charges and a statement of the reason you believe the service may not be covered. See the “Charging members for non-covered services” protocol in the UnitedHealthcare care provider administrative guide.”

Please click here to review the new  obstetrical ultrasound medical policy

Find this type of content useful? Follow my blog for new/updated reimbursement policy announcements, medical billing and coding guideline changes and anything else healthcare related.

Recent Blog Posts:

Posted in #unitedhealthcare, Prior Authorization Insurance Carrier Updates, Training, Updates

UHC Commercial Plans: some radiotherapies do not require prior auth

Posted on by KR2Medical Billing

This policy change applies to UHC Commercial Plans:

  • UnitedHealthcare Plan of the River Valley, Inc.
  • UnitedHealthcare Insurance Company of the River Valley
  • UnitedHealthcare of the Mid-Atlantic, Inc.
  • MAHP Life and Health Insurance Company
  • Neighborhood Health Partners
  • UHOne
  • All Savers (fractionation prior authorization requirement for All Savers will be delayed)
  • Rhode Island and Oxford Health Plan members will be excluded

If you are a provider seeing any of the patients with the above mentioned plans and refer them for some outpatient radiotherapies, then this change applies to you.

There are 8 Radiotherapy codes, when performed in outpatient setting will no longer require a prior authorization.

These codes are:

  • 37243-Vascular embolization or occlusion, for tumors, organ ischemia, or infarction
  • 61796-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61797-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 simple cranial lesion
  • 61798-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); 1 complex cranial lesion
  • 61799-Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator); each additional cranial lesion, complex
  • 61800-Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure)
  • 63620-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 spinal lesion
  • 63621-Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional spinal lesion (List separately in addition to code for primary procedure)

If you would like to read the full coverage of determination, please click here.

If you are a provider that is ordering other types of outpatient radiotherapy, please ubmit an online prior authorization request, sign in to Link to access the Prior Authorization and Notification tool. Select the “Radiology, Cardiology, Oncology and Radiation Therapy” box. After selecting “commercial” as the product type, you’ll be directed to another website to process the authorization requests.

Find this type of content useful? Follow my blog for more prior authorization updates, medical billing and coding guideline updates, and medical/reimbursement policy updates.

Recent Blog Posts:

Posted in #unitedhealthcare, Training, Updates

UHC Commercial: Genetic testing in NICU-catch underlying genetic conditions.

Posted on by KR2Medical Billing

This policy applies to commercial plans for patients that are in the Neonatal Intensive Care Unit (NICU) and who were born at 32 weeks’ gestation or older, and where a genetic condition is suspected, are eligible for select rapid tests through a new genetics program.

Below are some important information regarding this new program.

What is the effective date for this program?

July 1,2021

Who is Eligible for this new program?

Patients that were born at 32 weeks gestation or above where a genetic condition is suspected by the provider are eligible for select rapid test. Please refer to the clinical indicator document for suggestions on when an underlying genetic condition may be suspected.

What genetic tests are included in the NICU Genetic Testing program?

Test options will continue to be evaluated and updated. At this time, rapid whole exome sequencing (rWES), available through XomeDxXpress® , analyzes the exome, which is the part of the genome that is thought to include most mutations that impact health.

XomeDxXpress Information

Will the facility get reimbursed for the NICU Genetic Testing?

NO. The reimbursement will be only given to the participating laboratories directly.

How does this impact the facility’s current inpatient contract with UnitedHealthcare?
There is no impact to a facility’s current contract. The NICU Genetic Testing program is a new program, effective July 1, 2021, where tests pre-selected for inclusion in the program may be submitted directly to the approved laboratory for reimbursement. When a program approved test is utilized with the code UHC NICU, the laboratory will know to seek reimbursement from UnitedHealthcare directly and not the hospital.

Where to get more information?

• Laboratory Support: GeneDx has professionals, including genetic counselors, geneticists and clinicians, available to answer questions at no cost. For assistance, please contact GeneDx at Xpress@genedx.com, 888-729-1206.
• Genetic Counseling Services: InformedDNA, an in-network virtual genetic counseling practice, is available to provide pre-test and/or post-test genetic counseling and informed consent for genetic testing to the parents of your patients via telephone. To refer a patient, go to informeddna.com or call 800-975-4819. InformedDNA is in-network with most
UnitedHealthcare commercials plans.

What is RAPID (EXPEDITED) WHOLE EXOME SEQUENCING – TRIO (WES)?

Source: Medical College of Wisconsin

Laboratory Proper Billing and coding:

81415 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis

81416 Exome (e.g., unexplained constitutional or heritable disorder or syndrome); sequence analysis, each comparator exome (e.g., parents, siblings) (List separately in addition to code for primary procedure)

Partial Whole Exome and Whole Genome Sequencing medical policy:

Need to contact UHC ?

For more questions on NICU genetic testing, please contact United_Genetics@uhc.com.

To read the full Whole Exome and Whole Genome Sequencing, please click here.