This pharmacy bulletin outlines new or revised clinical programs and implementation dates. It’s available online for UnitedHealthcare commercial and UnitedHealthcare Oxford commercial plans.
Prior authorization and notification requirement updates
We’re making changes to certain advance notification and prior authorization requirements and are available for you in the 2021 Summary of Changes.
Reimbursement policy updates: February 2021
This month you’ll find updates for Medicaid, Medicare and Exchange plans.
Specialty Medical Injectable Drug program updates: February 2021
See the latest updates to requirements for Specialty Medical Injectable Drugs for UnitedHealthcare members.
SNF consolidated billing requirements for Medicare
Skilled nursing facilities (SNF) are required to use consolidated billing when submitting claims for post-acute inpatient SNF admissions for UnitedHealthcare Medicare Advantage members.
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UnitedHealthcare is transitioning to InterQual criteria
We will transition to InterQual criteria for all benefit plans effective May 1, 2021. We expect that using InterQual will further streamline our current clinical review processes while helping to reduce clinical decision turnaround times.
New prescription safety edits
To help increase patient safety and prevent abuse and fraudulent activity, UnitedHealthcare Community Plan is continuing to implement Concurrent Drug Utilization Review (cDUR) safety edits.
Exchange plan prior authorization updates
Effective April 1, 2021, prior authorization will be required for certain stereotactic body radiation therapy and stereotactic radiosurgery services for Exchange plan members in Arizona, Maryland, North Carolina, Oklahoma, Tennessee, Virginia and Washington.
VA CCN Provider Manual updates
Routine updates will be made to the 2021 Department of Veterans Affairs (VA) Community Care Network (CCN) Provider Manual in January, April, July and October.
Arizona: Evidenced-based guidelines transition
Effective May 1, 2021, UnitedHealthcare Community Plan of Arizona will be transitioning our evidence-based clinical care guidelines.
Effective May 1, 2021, you will need to submit prior authorization for Cinryze, Spinraza and Zolgensma for UnitedHealthcare Community Plan members in Maryland. These requirements will apply whether members are new to therapy or have already been receiving these medications
New York: Correction – Payment Policy change
In a September 2020 Network Bulletin article — New York Payment Policy Change — we incorrectly said CPT® code revisions to the New York Non-Covered Code Payment Policy applied to UnitedHealthcare Community Plan Essential Plan (EP).
Utah: Prior authorization letters will no longer be mailed beginning this spring
Effective May 1, 2021, we will no longer print and mail paper prior authorization letters to health care professionals in Utah. This applies to all UnitedHealthcare plans in the state. Instead, prior authorization letters will be available for viewing in Document Vault, our secure online repository of UnitedHealthcare reports and claim-related communications.