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COVID-19 Prior Authorization and Ongoing Patient Care Updates

Last update: April 7, 2020, 2:35 p.m. CDT

UnitedHealthcare is working to help people access health care to the fullest extent possible as we come together to address this national emergency. We’re adopting measures that will reduce administrative burden for physicians and facilities, helping members more easily access the care they need under their benefit plan, and adjusting programs and services, as needed, to protect members and help limit the spread of the COVID-19 virus in communities.

To help our members access the critical supplies they need and streamline operations for providers during this national emergency, UnitedHealthcare is making changes to several durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) processes and provisions. The following provisions for prior authorization, reimbursement of disposable supplies and proof of delivery are effective for Medicare Advantage, Medicaid and Individual and Group Market health plan members, with dates of delivery from March 31, 2020, until May 31, 2020. Coverage and payment is subject to member's benefit plan and the provider's contracts.

Prior Authorization   

  • For all COVID-19 discharges to home-based care requiring a respiratory assist device or a ventilator, the vendor can deliver on notification only to UnitedHealthcare for codes E0471, E0465, E0466 and E0467 for up to three months from time of delivery. Notification is requested and the claim must be submitted with the appropriate modifiers and diagnosis code (ICD-10). After the three-month period, a prior authorization will be required.
  • For orders involving COVID-19-related oxygen requests, oxygen can be delivered without prior authorization and does not need to meet current clinical criteria.
  • Where possible, we’re eliminating Face-To-Face evaluation requirements for the ordering provider for DMEPOS:
    • For prior authorizations for services that were completed before Oct. 1, 2019, a new prior authorization is required. Provider may complete a Face-To-Face assessment via telehealth.
    • For prior authorizations for services that were completed on Oct. 1, 2019, or later, UnitedHealthcare is extending prior authorizations through Sept. 30, 2020.          
    • For new DMEPOS prior authorizations, providers may complete a Face-To-Face assessment via telehealth.
  • DMEPOS evaluation requirements remain in effect for complex rehab technology (CRT) and orthotics and prosthetics. However, vendors may use their own technology, if available, to minimize in-person contact.
  • Prior authorization is not required for a DMEPOS repair when the claim uses the repair modifier.
  • Consistent with existing policy, prior authorization is not required for breast pumps.

Reimbursement – Disposable Supplies

  • The following changes to disposable supply processes for these disposable supply codes will help maintain member supplies:
    • For initial orders, we’ll reimburse beyond 30 days to cover a 30- to 45-day supply depending on packaging.
    • For second orders, we’ll reimburse an additional 15-day supply to allow for overlap.
    • For remaining orders, vendors may manage frequency and duration to help members maintain sufficient product on hand, but it is not to exceed 45 days on hand. Supply limits still apply.

Proof of Delivery

A physical signature from the patient is not required, but the vendor must note the time and date of delivery and relationship to member, in addition to maintaining required documentation for follow-up requests. 

In response to new guidance from the American Society for Reproductive Medicine, UnitedHealthcare is implementing a temporary change in coverage protocol for embryo cryopreservation. This will help members avoid mid-cycle disruption to infertility treatment accessed through their benefit plan during this challenging time.

The following temporary change and important steps for health care providers apply to dates of service from March 17, 2020 until April 30, 2020:

Temporary Change

  • This temporary change in coverage protocol applies to infertility treatment care plans for members who have started an in vitro fertilization (IVF) cycle and are ready for retrieval and embryo transfer, which is interrupted mid-cycle. It does not apply to previously scheduled cryopreservation services.
  • We will provide embryo cryopreservation coverage to fully insured members with infertility benefits, where plan benefits had not previously included embryo cryopreservation coverage.
    • Members with fully-insured coverage, may, in some instances, already have benefit coverage for embryo cryopreservation when the issued policy includes a state-mandated requirement for this coverage. In that instance, the member will receive the higher level of coverage: either this temporary change in coverage protocol or the state-mandated requirement for coverage.
  • For members in self-funded benefit plans with infertility benefits who do not have coverage for embryo cryopreservation and storage, coverage will be provided if their plan sponsor opts in to offer this change in coverage protocol during this time.
  • The plan benefit will define the member cost share.
  • Other infertility treatment care plan issues pertaining to adverse determinations affected by the COVID-19 pandemic may be addressed through a peer-to-peer review.

Important Steps for Health Care Providers

  • Retrieval and Cryopreservation Have Not Occurred: If retrieval and cryopreservation of embryo(s) haven’t occurred and previously requested prior authorization has been denied, please request a peer-to-peer review by calling us at 800-955-7615 or via secure email at UHC_PeertoPeer_Scheduling@uhc.com. The peer-to-peer review will focus on the prior authorization related to these services. In your request, please provide detailed information on the indication for cryopreservation at this time.
  • Retrieval and Cryopreservation Have Occurred: If retrieval and cryopreservation of embryo(s) have occurred, please request an appeal of your claim related to these services. Instructions on submitting an appeal can be found on the Provider Remittance Advice you received for the claim or in the Provider Administrative Guide/Care Provider Manual available on UHCprovider.com/guides.

The following prior authorization provisions apply to all Medicare Advantage, Medicaid and Individual and Group Market health plans and are effective March 24, 2020:

  • Suspension of prior authorization requirements to a post-acute care setting through May 31, 2020. Details:
    • Waiving prior authorization for admissions to long-term acute care facilities (LTAC), acute inpatient rehabilitation (AIR), and skilled nursing facilities (SNF).
    • Consistent with existing policy, the admitting facility must notify us within 24 hours for weekday admissions or by 5 p.m. local time on the next business day for weekend and holiday admissions.
    • Length of stay reviews still apply, including denials for days that exceed approved length.
    • Discharges to home health will not require prior authorization.
    • UnitedHealthcare is able to help providers with patient discharge planning to lower levels of care settings. Please email COVID-19dischargeplanning@uhc.com for assistance.
  • Suspension of prior authorization requirements when a member transfers to a new provider through May 31, 2020. Details:
    • Providers are not required to submit a new prior authorization when a member moves to a different yet similar site of care for the same service (e.g., hospital transfers or practice transfers).
    • For inpatient and post-acute admissions, consistent with existing policy, the admitting facility must notify us within 24 hours for weekday admissions or by 5 p.m. local time on the next business day for weekend and holiday admissions.
    • For other transfer circumstances, such as outpatient services, please contact us at the phone number on the back of the member’s ID card to transfer the existing authorization.
  • Suspension of review for site of service until April 30, 2020 for the surgical codes listed here .

Additionally, prior authorization is not required for COVID-19 testing and COVID-19 testing-related visits during this emergency period.

We will not require prior authorizations for diagnostic radiology (diagnostic imaging) of the chest for COVID-19 patients during this national emergency. We urge providers to submit notification for CPT® codes 71250, 71260, 71270 for members with a COVID-19 diagnosis or suspected diagnosis, and who are enrolled in Medicaid and Individual and Group Market health plans. No notice is necessary for Medicare. Notification allows us to coordinate the care of our members who may have COVID-19 and better support them in their health care journey. For all other chest CTs, prior authorization continues to be required.

Out of an abundance of caution, we’re pausing all HouseCalls and Optum At Home in-person visits with our members until further notice, effective immediately (March 20, 2020). This does not apply to services provided somewhere other than in private homes, such as telephone services and treating patients in skilled nursing facilities.

Keeping our members, care providers and their families healthy and safe is our top priority during this challenging time. Please be assured that we’re working diligently to determine how we can safely resume HouseCalls and Optum At Home visits as quickly as possible. We’re continuously monitoring national and local updates from the Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS) and other outlets to adjust our policies as needed. We’ll provide an update as soon as we have more information.

UnitedHealthcare is closely monitoring the drug supply chain to determine if any coverage changes are necessary.

Early Prescription Refills

UnitedHealthcare members can fill existing prescriptions early (up to a 90-day refill) through direct pharmacy or mail order. To get an early refill, members can call the pharmacy number on their ID card or speak directly to a pharmacist.

We may also temporarily suspend or relax additional policies, as needed, in regions where inpatient capacity is most compromised and at risk.

Systems are being updated to reflect these changes. Please check back often for the latest information.

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


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We’ll be making daily updates to this site. Be sure to check back often for the latest information. 

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Disclaimer:

The benefits described on this website describe federal requirements and UnitedHealthcare national policy. Additional benefits may be available in some states and under some plans.