Oxford has engaged eviCore to perform initial reviews of pre-certification requests.
eviCore has established an infrastructure to support the review, development, and implementation of comprehensive outpatient imaging criteria. The radiology and cardiology evidence-based guidelines and management criteria are available on the eviCore website. In addition, eviCore established coding and billing guidelines to help ensure appropriate billing of radiation oncology codes.
eviCore handles all pre-certification requests. To pre-certify a radiology, cardiology or radiation therapy procedure, call eviCore at 1-877-PRE-AUTH (1-877-773-2884) or visit the Prior Authorization and Notification tool at UHCprovider.com/paan.
Oxford also requires a minimum care provider accreditation and certification requirements for MRI, PET, CT and nuclear medicine studies. Find more detailed information in the Radiology Procedures Requiring Precertification for eviCore Health Care Arrangement policy at OxfordHealth.com > Providers (or Facilities) > Tools and Resources > Medical Information > Radiology & Radiation Therapy Information or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. (Refer to the back of the member’s ID card for the applicable website.)
The referring care provider is responsible for contacting eviCore to request prior authorization and to provide sufficient history to verify the appropriateness of the requested services. Our policy does not permit prior authorization requests from persons or entities other than referring care providers.
The imaging facility must confirm before providing service that eviCore issued an authorization number. In the case of urgent examinations, or cases in which, in the opinion of the attending care provider or other health care professional, a change is required from the authorized examination, and the eviCore offices are unavailable, you may perform the services and request a new or modified authorization number. You must make the request within 2 business days of the service date through the Imaging Care Management department for Radiology. You should make the request immediately if the eviCore offices are available.
eviCore will review the clinical justification for the request using the same criteria as a routine request. See the How to Contact Oxford Commercial section for additional information.
Obtain prior authorizations for outpatient radiology, cardiology, and radiation therapy procedures using the Prior Authorization and Notification tool.
Oxford engages eviCore to perform initial reviews of requests for pre-certification of for echocardiogram, stress echocardiogram, cardiac nuclear medicine studies, cardiac CT, PET and MRI and cardiac catheterizations procedures. eviCore established correct coding and evidence-based criteria to determine medical necessity and appropriate billing of cardiology services. The cardiology evidence-based criteria and management criteria are available on the eviCore website at evicore.com. Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.
The utilization review process involves matching the member’s clinical history and diagnostic information with the approved criteria for each imaging procedure requested. Qualified health care providers make utilization review decisions for diagnostic procedures. eviCore may assign data collection for clinical certification of imaging services to non-medical personnel working under the direction of qualified health care providers. You receive communication of review determinations for non-urgent care by fax/telephone within 2 business days of receiving all the necessary information. For urgent requests, eviCore communicates their findings for medical necessity within 24 hours of receiving all required information.
For members, eviCore accepts requests for retrospective clinical certification review of medically urgent care up to 2 business days after care has been given for radiology and 15 days for cardiac catheterization, if the services are performed outside eviCore’s hours of operation and rendered on an urgent basis. eviCore makes retrospective review decisions within 30 business days of receiving all necessary information. If your request is not authorized, they send a review determination in writing to the member and the requesting care provider within 5 business days of the decision. All authorization reference numbers are issued at the time of approval. eviCore uses the reference CPT code as the last 5 digits of the authorization number. We require the submission of clinical office notes for specific procedures. Clinical notes include the member’s medical record and/or letters received from specialists.
For a list of procedures requiring pre-certification through eviCore, refer to the Cardiology Procedures Requiring Precertification for eviCore Health Care Arrangement policy at:
OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com >Policies and Protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies.
Oxford has engaged eviCore to perform prior authorization and medical necessity reviews for all outpatient radiation therapy services. Oxford continues to be responsible for decisions to limit or deny coverage and for appeals.
For a list of procedures requiring pre-certification through eviCore, refer to the clinical policy titled Radiation Therapy Procedures Requiring Precertification for eviCore Health Care Arrangement at OxfordHealth.com > Providers > Tools & Resources > Medical Information > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s ID card for the applicable website.
eviCore performs a medical necessity review before rendering services. To obtain prior authorization for a course of radiation therapy, or rendering a Diagnostic Radiology procedure, use the Prior Authorization and Notification tool on Link. See UHCprovider.com/priorauth for more information.
We require the submission of clinical office notes for specific procedures if a medical necessity review and utilization review is not conducted before services are performed. Clinical notes include the member’s medical record and/or letters received from specialists. Supporting clinical information provided by the ordering care provider must contain the ordering/referring care provider’s name and signature, address, phone and fax numbers, specialty, and tax identification number. It must also include all of the following information:
Note: eviCore policy does not permit prior authorization requests from persons or entities other than the following:
Certain Oxford products require referrals for radiology, cardiology or radiation therapy from the member’s PCP. If your patient is enrolled in one of these benefit plans, they are required to obtain a referral before seeing you for an initial visit.
We continue to process claims from participating care providers for radiation therapy services. You receive payment directly from us.
You may not balance bill the member if a claim is denied because medical necessity was not demonstrated. We will offer all appropriate appeal rights for any service that is not approved for payment.
Prior authorization is not required when cardiology procedures are provided in the ER, observation unit, urgent care facility, or during an inpatient stay.
See a list of Services Requiring Prior Authorization at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policy Index > Services Requiring Prior Authorization or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s ID card for the applicable website.
The clinical criteria consistent with existing UnitedHealthcare and Oxford policies are available on evicore.com.
You can verify prior authorization requirements by:
Oxford delegated Optum, a UnitedHealth Group company, to perform reviews for infertility services under their Managed Infertility Program (MIP) for all Oxford Commercial members with an infertility benefit. Optum uses MIP to promote both quality of care and continuity of service by supporting members through every aspect of the infertility process. Optum infertility nurse case managers provide support and help members make informed decisions about infertility treatment and care through treatment education, considerations in choosing where to obtain care, and assistance navigating the health care system.
For Oxford products, the rendering care provider is required to request prior authorization and/or notification of services. Make this request using the Managed Infertility Program Treatment form. Provide sufficient information to determine the medical necessity of the requested services.
Optum has been diligent in their research to help ensure the clinical policies and guidelines they use are consistent with best practices and state mandates.
Get the Managed Infertility Program (MIP) Prior Authorization template by either:
OrthoNet, a musculoskeletal disease management company, is our network manager for most musculoskeletal services.
OrthoNet’s orthopedic division performs utilization management review of requested services to help ensure they meet approved clinical guidelines for medical necessity.
OrthoNet conducts the review by determining medical necessity and medical appropriateness, and initiates discharge planning,
as appropriate. OrthoNet will base the results on clinical information and some or all of the following criteria/tools:
Services performed by the following specialties (participating and non-participating) are subject to utilization review by OrthoNet’s orthopedic division regardless of the diagnosis:
OrthoNet’s orthopedic division manages services provided by the facilities below (participating and non-participating) when billed together with certain ICD-10 codes:
For a complete list of orthopedic diagnosis codes, or for more information on Oxford’s arrangement with OrthoNet, refer to the Orthopedic Services policy at OxfordHealth.com > Providers or Facilities > Tools & Resources > Medical and Administrative Policies > Medical & Administrative Policy Index or UHCprovider.com/policies-protocols > Commercial Policies > UnitedHealthcare Oxford Clinical, Administrative and Reimbursement Policies. Refer to the back of the member’s ID card for the applicable website.
Oxford delegated certain administrative services related to outpatient physical and occupational therapy services to OptumHealth Care Solutions, LLC (Optum). Hospital outpatient treatment facilities, outpatient facilities at or affiliated with rehabilitation hospitals are considered outpatient settings for physical and occupational therapy.
All physical and/or occupational therapy visits require utilization review and an authorization, including the initial evaluation. After registering on myoptumhealthphysicalhealth.com, click on the Forms link and locate the Patient Summary Form. The treating care provider or health care professional must submit a Patient Summary Form to Optum®. They may submit the completed form through the Optum website myoptumhealthphysicalhealth.com. Send the forms within 3 days of initiating treatment. They must be received within 10 days from the initial date of service indicated on the form. Optum adjusts the initial payable date when they receive the forms outside of the 10-day submission requirement.
The Patient Summary Form must include the initial visit. If Optum does not receive the required form(s) within this time frame, they deny the claim. Optum reviews the services requested for medical necessity. After the initial approved visits have occurred, if a member’s care requires additional visits or more time than was approved, you must submit a new Patient Summary Form with updated clinical information.
Note: Prior authorization is not required for certain groups.
OptumHealth Care Solutions, LLC (Optum) manages our chiropractic benefit. To receive standard chiropractic benefit coverage, members must obtain an electronic referral from their PCP. PCPs perform the customary initial comprehensive differential diagnosis with the necessary and appropriate workup.
You may request a chiropractic referral for a maximum of one visit within 180 days (6 months). Participating chiropractors must complete and submit Patient Summary Forms to Optum® for services performed.
They may submit the Patient Summary Forms through the Optum website at myoptumhealthphysicalhealth.com. They must submit the form within 3 business days and no later than 10 business days following the member’s initial visit or recovery milestone. We must receive the patient summary form within 10 days from the initial date of service indicated on the form. Optum adjusts the initial payable date when they receive the forms outside of the 10-day submission requirement.
Once they receive the forms, Optum reviews the services requested for medical necessity and makes denial determinations.
If a member’s care requires more visits or time than was approved, you must submit a new Patient Summary Form with updated clinical information after the initially approved visits have occurred.
According to your contract with Optum, the member may not be balance billed for any covered service not reimbursed if you do not submit the Patient Summary Form, or for those services which do not meet medical necessity or coverage criteria. However, you may file an appeal.
Only members who have the alternative medicine rider have coverage for acupuncture. If a member does not have the alternative medicine rider, we deny requests to cover acupuncture, even if a letter of medical necessity has been submitted. Acupuncture services must be rendered in-network and performed by one of the following care provider types:
The pharmacy benefit plan includes a dynamic medication list, referred to as the Prescription Drug List (PDL), and various clinical drug utilization management programs. We base these programs on FDA-approved indications and medical literature or guidelines.
The PDL contains medications in 3 tiers. Tier 1 is the lowest cost option, and Tier 3 is the highest cost option. Some groups have a 4-tier benefit design.
To help make medications more affordable, consider whether a Tier 1 or Tier 2 alternative is appropriate if the member is currently taking a Tier 3 medication. We perform ongoing reviews of the PDL and make updates at least twice per year. Medications requiring notification or prior authorization are noted with a “PA,” medications that require step therapy are noted with “ST” and supply limits with “SL.”
The UnitedHealthcare PDL Management Committee, a group of senior care providers and business leaders, makes tier decisions and changes to the PDL based on a review of clinical, economic and pharmacoeconomic evidence.
The UnitedHealthcare National Pharmacy and Therapeutics (PT) Committee is responsible for evaluating and providing clinical evidence to the PDL Management Committee to help assign medications to tiers on the PDL. The information provided by the PT Committee includes evaluation of a medication’s role in therapy, its relative safety and its relative efficacy.
The PT Committee reviews and approves clinical criteria for prior authorization and step therapy programs, and supply limits. In addition to medications covered under the pharmacy benefit, the PT Committee is responsible for evaluating clinical evidence for medications, which require administration or supervision by a qualified, licensed health care professional.
The PT Committee is comprised of medical directors, network care providers, consultant physicians, clinical pharmacists and pharmacy directors.
For more information regarding Oxford’s Pharmacy Management Program, go to oxhp.com.
We receive the majority of prescription claims electronically for payment. Within seconds, our systems record the member’s claim and review past prescription history for potential medication-related problems. DUR helps review for potentially harmful medication interactions, inappropriate utilization and other adverse medication events to maximize therapy effectiveness withinthe appropriate medication usage parameters. There are 2 types of DUR programs: concurrent and retrospective.
The C-DUR program performs online, real-time DUR analysis at the point of prescription dispensing. This program screens every prescription before dispensing for a broad range of safety and utilization considerations. C-DUR uses a clinical database to compare the current prescription to the member’s inferred diagnosis, demographic data and past prescription history. The C-DUR program uses criteria to identify potential inappropriate medication consumption, medical conflicts or dangerous interactions that may result if the prescription is dispensed.
If the C-DUR identifies a potential problem, it notifies the dispensing pharmacist by sending either a soft alert (warning message) or a hard alert (a warning message also requiring the pharmacist to enter an override). The dispensing pharmacist uses professional judgment to determine appropriate interventions, such as contacting the prescribing care provider or other health care professional, discussing concerns with the member and dispensing the medication.
The R-DUR program involves a daily review of prescription claims data to identify patterns in prescribing or medication utilization suggesting inappropriate or unnecessary medication use. The program uses a clinical database to review member profiles for potential over-or under-dosing as well as duration of therapy, potential drug interactions, drug-age considerations and therapy duplications.
You and other prescribers receive a member-specific report outlining opportunities for intervention and asking them to respond to specific issues and concerns.
Based on the member’s benefit plan design, selecting high-risk or high-cost medications may require advance notification to be eligible for coverage. We may ask you to provide information explaining medical necessity and/or past therapeutic failures. A representative will collect pertinent clinical data for the service requested. If we do not approve the prior authorization, a pharmacist or medical director, in keeping with state regulations, makes the final coverage determination. We notify you and the member of the decision.
Certain medications may be subject to step therapy, also referred to as First Start for New Jersey members. The step therapy program requires a trial of a lower-cost, Step 1 medication before a higher-cost, Step 2 medication is eligible for coverage.
When a member presents a Step 2 medication at the pharmacy, our systems may automatically check the claims history to see if a Step 1 medication is in the claims history. The medication may automatically process. If not, you may request a coverage review. If we do not approve the medication, a pharmacist or medical director, in keeping with state regulations, makes the final coverage determination. We notify you and the member of the decision.
Some medications are subject to supply limits. We base supply limits on FDA-approved dosing guidelines as defined in the product package insert and the medical literature or guidelines and data supporting the use of higher or lower dosages than the FDA-recommended dosage. This program focuses on select medications or categories of medications that are high-cost and/or are frequently used outside of generally accepted clinical standards.
When a pharmacist submits an online prescription claim, the online claims processing system compares the quantity entered with the allowable limits.
If the prescription exceeds the established quantity limits, we reject the claim, and the pharmacist receives a message. The current supply limit for the medication is displayed in the message. For New York and New Jersey fully insured business, a subset of medications has coverage criteria available to obtain quantities beyond the established limit, if medically necessary.