February 01, 2022

Updates for Oxford policies, prior authorizations and claims

Medical drug policies
To help streamline and simplify the provider experience, UnitedHealthcare Oxford will move from Oxford-branded medical drug policies to the UnitedHealthcare-branded medical drug policies. The clinical coverage criteria between the policies are identical. View the UnitedHealthcare Commercial Medical & Drug Policies and Coverage Determination Guidelines.

Injectable medication prior authorization process change for certain specialty drugs
Effective May 1, 2022, Optum, an affiliate company of UnitedHealthcare, will start managing prior authorization requests for certain medical benefit medications for UnitedHealthcare Oxford plan members. This is currently in place for UnitedHealthcare commercial plan members.

Requesting prior authorizations using the Specialty Guidance Program tool in the UnitedHealthcare Provider Portal is designed to reduce the turnaround time for a determination by leveraging pre-programmed questions for the provider to answer that may result in real-time approvals. The system will document clinical requirements during the intake process and prompt you to provide responses to the clinical criteria questions. You can also call 888-397-8129 for help with a prior authorization.

How to request prior authorization

Submit prior authorization requests online using the Specialty Guidance Program tool.

  • Sign in to the UnitedHealthcare Provider Portal using your One Healthcare ID
  • Select the “Prior Authorization” tab in the menu, and you will be redirected to the prior authorization tool
  • Select “Submission & Status” under the Specialty Pharmacy Transaction header
  • Be sure to attach medical records, if prompted

Please use this online process when requesting notification/prior authorization for a specialty medication listed under the injectable medications section of the Enterprise Prior Authorization List or a medication that is required to be provided from an indicated specialty pharmacy, as noted below.  

You’ll need to request a prior authorization once an existing authorization expires or if you change the therapy. Changes in therapy include place of therapy, dose or frequency of administration. If you have already obtained an authorization for a member, that authorization is still active until the original expiration date.

Learn more about the Specialty Guidance Program.

UnitedHealthcare Oxford medical injectable drugs claims processing updates
UnitedHealthcare Oxford has made enhancements to our processing applications for injectable medications covered under the medical benefit. These enhancements have streamlined authorization matching criteria to help ensure claims are accurately processed according to the prior authorization that was approved for the billed service. Providers need to validate the accuracy of the authorized services before billing. A claims payment could be reduced if the billed services do not match the details on the prior authorization. 

Please contact your provider advocate or network contract manager.