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 are available for you in the 2021 Summary of Changes.
Reimbursement policy updates: May 2021
This month, you’ll find updates for Medicaid and commercial plans.
Specialty Medical Injectable Drug program updates: May 2021
See the latest updates to requirements for Specialty Medical Injectable Drugs for UnitedHealthcare members.
CAR-T therapy prior authorization updates
Effective July 1, 2021, we’ll require prior authorization for Breyanzi and Abecma (Ide-Cel) or related services, including outpatient or inpatient evaluation and the chimeric antigen receptor T-cell (CAR-T) outpatient or inpatient episode. This applies to UnitedHealthcare Community Plan, Medicare Advantage and commercial plans.
Oxford injectable cancer therapy authorization program update
CT, NJ, NY
Effective Aug. 1, 2021, Optum, an affiliate company of UnitedHealthcare, will manage UnitedHealthcare Oxford prior authorization requests for outpatient injectable chemotherapy and related cancer therapies for members with a cancer diagnosis.
Commercial prior authorization and site of service changes
Starting Aug. 1, 2021, for UnitedHealthcare commercial benefit plans, including Oxford, Neighborhood Health Partnership and UnitedHealthcare of the River Valley, we’re changing our prior authorization requirements and site of service medical necessity reviews for some surgical and office-based procedures.
Exchange prior authorization and site of service reviews
AZ, MD, NC, OK, TN, VA, WA
Starting Aug. 1, 2021, for UnitedHealthcare Individual Exchange plans, we’re making changes to the prior authorization requirements and site of service medical necessity reviews for certain surgical and screening colonoscopy procedures.
Medicare and DSNP: Prior authorization and site of service reviews
AR, CO, CT, FL, NJ, NV, NY, TX
Starting June 1, 2021, we’re expanding our notification/prior authorization requirements and site of service medical necessity reviews to include certain procedures/CPT® codes for Dual Special Needs Plans (DSNPs) in New Jersey. We’ll only require notification/prior authorization if these procedures/CPT codes will be performed in an outpatient hospital setting.
Kentucky: Prior authorization and site of service reviews
Starting Aug. 1, 2021, for UnitedHealthcare commercial plans, we’re expanding our prior authorization requirements to include Kentucky for certain surgical, screening colonoscopy, office and MRI/CT imaging procedures.
Electronic payments required soon for UnitedHealthcare Community Plans
HI, MD, NC, OH, VA, WA
We’re no longer sending paper checks for health care professional payments, unless mandated by applicable laws. Instead, you’ll have 2 options for receiving payment from UnitedHealthcare.
Medical claims require request pre-pay facility sepsis audit
AK, AL, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, OH, OK, OR, PA, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY
Effective July 1, 2021, Medicare Advantage and commercial claims for sepsis-related treatment may be reviewed on a pre-payment or post-payment basis. These reviews promote accurate diagnosis and treatment of sepsis and help ensure the claim is coded and billed at the appropriate treatment level.
Member and patient support for Community and State
AZ, CA, FL, HI, KS, KY, LA, MD, MI, MO, MS, NE, NJ, NY, OH, PA, RI, TN, TX, VA, WA, WI
You will find resources to help you care for your patients who are our members. Topics include: Utilization review, members’ rights and responsibilities for Community and State, coordination of care between primary care practitioners and specialist, care management, pharmacy updates, cultural competencies, appointment access standards, support for language services and clinical guidelines.