November 2021 policy and protocol overview

Your notice of protocol and policy changes from UnitedHealthcare

Appendix Bulletins

Medical policy updates: November 2021
This month, you’ll find updates for Medicaid, Medicare, Exchange and commercial plans.

Pharmacy updates
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 that are available for you in the 2021 Summary of Changes.

Reimbursement policy updates: November 2021
This month, you’ll find updates for Medicaid and commercial plans.


Specialty Medical Injectable Drug program updates: November 2021
See the latest updates to requirements for specialty medical injectable drugs for UnitedHealthcare members.

Commercial plan 2022 prescription drug list update
The Jan. 1, 2021, prescription drug list and pharmacy benefit updates for UnitedHealthcare commercial plans are now available for review.

Specialty pharmacy drug list update – Nulibry ™
Effective for dates of service beginning on Dec. 1, 2021, we’re adding the following specialty medications to our specialty pharmacy requirements drug list for UnitedHealthcare commercial plans.


Prior Authorization

Prior authorization and site of service updates
Starting Feb. 1, 2022, we’re updating the prior authorization requirements and site of service medical necessity reviews for certain surgical procedures.

Medicare and DSNP: Prior authorization and site of service expansion
Starting May 1, 2022, for UnitedHealthcare Medicare Advantage plans, we’re expanding our prior authorization requirements and site of service medical necessity reviews for certain surgical procedures.

Medicare clinical submission requirement change
Effective Feb. 1, 2022, UnitedHealthcare will require you to obtain prior authorization for PT, OT and ST services delivered at multi-disciplinary offices and outpatient hospital settings. These prior authorization requirements apply to patients new to therapy and those who are currently receiving therapy.

Prior authorization changes for private duty nursing
Starting Feb. 1, 2022, we’ll require prior authorization for the complimentary benefit of private duty nursing (HCPCS code T1000) offered to designated Medicare Advantage® retiree plans through UnitedHealthcare Retiree Solutions.

Cardiac event monitoring prior authorization change
Effective Feb. 1, 2022, we will update our cardiology prior authorization program to include codes related to implantable loop recorders for UnitedHealthcare Medicare Advantage members.

Electrophysiology implant prior authorization update
Starting Dec. 1, 2021, we’ll no longer require prior authorization and notification for electrophysiology implant procedures subject to the UnitedHealthcare outpatient cardiology notification/prior authorization protocol when performed and appropriately billed as an inpatient service for UnitedHealthcare Community Plan, Medicare Advantage®, commercial and Exchange plan members.

Correction: Pain management and injection prior authorization
In the August edition of the Network Bulletin, we informed you that starting Nov. 1, 2021, we are expanding our prior authorization requirements for UnitedHealthcare commercial plans including All Savers, River Valley, Neighborhood Health Partnership, UnitedHealthcare West and MidAtlantic Health.

Arizona: Facet injection prior authorization codes changes
Effective Feb. 1, 2022, we’re adding 6 facet injection procedure-related CPT® codes (64490‒64495) to the prior authorization list for UnitedHealthcare commercial plan members in Arizona.

Digital Transition

Appeal decision letters won’t be mailed in 2022 
Beginning Feb. 11, 2022, we will no longer mail appeal decision letters for Medicare Advantage and commercial plans.

Northeast: Medical PRAs going paperless in February
Starting Feb. 4, 2022, for most* UnitedHealthcare plans in the region, we will no longer print and mail paper provider remittance advice (PRAs) for medical claims to network health care professionals and facilities (primary and ancillary).


Plan expansions

New Medicare Advantage plans for 2022
Effective Jan. 1, 2022, more UnitedHealthcare® Medicare Advantage plans, including Dual Special Needs Plans (DSNP), will be available with options in new states and counties.

Massachusetts: New health plan for dual-eligible members
Effective Jan. 1, 2022, UnitedHealthcare Connected® for One Care (Medicare-Medicaid plan) will be available to individuals in Massachusetts who are eligible for both Medicare and Medicaid.

Nebraska: Heritage Health Adult benefit expansion
Heritage Health Adult (HHA) has expanded Medicaid coverage to patients, ages 19–64, whose income is at or below 138% of the federal poverty level. 

Other Updates

2022 changes to the Medicare Advantage hospice benefit
Starting Jan. 1, 2022, the hospice benefit component of the Centers for Medicare & Medicaid Services (CMS) Value-Based Insurance Design (VBID) model will change the UnitedHealthcare® Medicare Advantage member’s hospice service benefits and how those benefits are billed in Alabama, Illinois, Oklahoma and Texas.

UnitedHealthcare — committed to price transparency and disclosure
As part of our commitment to improving the health care system, all Participation Agreements between UnitedHealthcare and health care professionals, medical groups, facilities and ancillary providers will be interpreted consistently with government-mandated price transparency and disclosure. 

CPT® is a registered trademark of the American Medical Association.