Medical policy updates: April 2021
This month, you’ll find updates for Medicaid, Medicare, Exchange and commercial plans.
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 these are available for you in the 2021 Summary of Changes.
Reimbursement policy updates: April 2021
This month you’ll find updates for Medicaid, Medicare, Exchange and commercial plans.
Specialty Medical Injectable Drug program updates: April 2021
See the latest updates to requirements for Specialty Medical Injectable Drugs for UnitedHealthcare members.
Outpatient Procedure Grouper mapping update
On July 1, 2021, the UnitedHealthcare Outpatient Procedure Grouper (OPG) Exhibit will be updated to reflect quarterly reimbursement for outpatient and other procedures for commercial members.
New codes added to the prior authorization list
Starting July 1, 2021, we’re adding additional codes to the prior authorization list for UnitedHealthcare Medicare Advantage plans and some UnitedHealthcare Community Plans (Medicaid, Long-Term Care).
Genetic and molecular lab testing updates
We’re making some changes to our Genetic and Molecular Lab Testing Program, including new requirements for prior authorization and lab test registration. These changes apply to UnitedHealthcare plans that currently require prior authorization for certain genetic and molecular tests performed in an outpatient setting through BeaconLBS.
Genetic and molecular testing code updates
Starting July 1, 2021, we’ll require prior authorization for additional genetic and molecular testing CPT® codes for our commercial plan members. This is a part of the prior authorization program for genetic and molecular testing performed in an outpatient setting.
Coverage for preimplamtation genetic testing
Starting July 1, 2021, preimplantation genetic testing (PGT) will be covered as a standard benefit for eligible UnitedHealthcare commercial plan members when they or their partners are carriers for a specific genetic disorder.
Fertility preservation for iatrogenic infertility is now covered
Effective July 1, 2021, fertility preservation for iatrogenic infertility is covered for fully insured commercial members who are on a new plan or upon renewal of their existing plan after this date.
Maternity claim submission requirement coming
Starting July 1, 2021, all participating health care professionals and inpatient acute care facilities must report gestational age on maternity claims using the appropriate diagnosis code. This requirement is for commercial plans.
New early elective delivery requirements
Effective July 1, 2021, for commercial members, all births planned between 37 and 39 weeks of gestational age will need new documentation.
Prior authorization for anti-emetics
Effective July 1, 2021, prior authorization is required for 8 anti-emetics codes for members with a cancer diagnosis. (Prior authorization requirements for outpatient injectable chemotherapy are not affected by this addition.) This requirement is for UnitedHealthcare Community Plan, Exchange and commercial plan members who require prior authorization today for outpatient injectable chemotherapy.
Specialty Pharmacy Drug List update
Effective July 1, 2021 we’re adding 2 specialty medications, OxlumoTM and Amondys-45, to our Specialty Pharmacy Requirements Drug List for UnitedHealthcare commercial plans.
Change in post-acute care management
Arizona, Colorado, Iowa, Michigan, Minnesota, North Dakota, Nebraska, South Dakota
Effective June 1, 2021, NaviHealth will start managing certain post-acute care administrative processes for Medicare Advantage members.
New prior authorization for CGM
Arizona, California, Florida, Hawaii, Kansas, Kentucky, Maryland, Massachusetts, Michigan, New York, Ohio, Pennsylvania, Rhode Island, Texas, Virginia, Washington, Wisconsin.
Prior authorization will be required for personal long–term continuous glucose monitors (CGM) used for the management of type-2 intensive insulin and gestational diabetes. The durable medical equipment (DME) vendor or other rendering provider that has received a physician order for a CGM is required to obtain prior authorization. This requirement is for Medicaid, Long-Term Care and Medicare-Medicaid (MMP) plan.
Alabama and Georgia: Home health review process changes
Effective July 1, 2021, for UnitedHealthcare Medicare Advantage and Dual Special Needs Plans, we will be launching a pilot program for the implementation of an initial authorization and continuation of care reviews for Home Health Agencies (HHAs).
Maryland: Plan changes in Prince George’s and Charles Counties
Effective April 1, 2021, Prince George’s and Charles counties will no longer be part of the capitated radiology program for our Gated health maintenance organization (HMO) (M.D. IPA and Optimum Choice) members. Effective on that date, members who previously had RAD=PG and RAD=CHRLS on their member ID cards will have access and may be referred to the full contracted radiology network
New Jersey: JW Modifier – Drug Waste Reimbursement
Effective May 1, 2021, UnitedHealthcare Community Plan of New Jersey will deny the claim lines billed with the JW modifier.
Rhode Island: New behavioral health copay regulation
Starting Jan. 1, 2021, we eliminated the behavioral health copay when a UnitedHealthcare commercial plan member sees a behavioral health specialist and a primary care physician: