Complete Story
06/15/2023
United Healthcare
United Healthcare Managed Care Committee Member
Shelby Jensen, CHONC - Newland Medical Associates
Educational videos
IMRT Unbundling and exceeding MUE
Procedure to procedure code pair unbundling
Chemo administration with E/M service
UnitedHealthcare Cancer Support Program
The UnitedHealthcare Cancer Support Program provides individualized coaching and education for adult and pediatric patients who may be at high risk for treatment complications or side effects. Our experienced oncology nurse case managers collaborate with you to help support and reinforce the treatment plan you’ve developed with our doctor, and provide information and resources to patients.
The UnitedHealthcare Cancer Support Program currently assists more than 30,000 cancer patients annually1 and our oncology nurse case managers have a 99% member satisfaction2 rate.
More claim Letters Going Digital on July 14
Starting July 14, 2023, UnitedHealthcare will no longer mail claim letters to most* medical network health care professionals and facilities for UnitedHealthcare® Medicare Advantage plans. While many claim letters have already moved to digital, these can be found in the Document Library Claim Letters folder. You’ll be able to view them 24/7 through the UnitedHealthcare Provider Portal or an Application Programming Interface (API).
If you use an outside vendor, such as a revenue cycle management company or lock box service, please ensure they’re aware of the following changes and digital workflow options.
Updated Requirements for Gastroenterology Services
To provide an opportunity for physician education and to allow UnitedHealthcare to collect more data on which providers should be eligible for our previously announced 2024 Gold Card administrative simplification program, we will be implementing an Advance Notification process, rather than Prior Authorization, for non-screening gastroenterology (GI) procedures.
Beginning June 1, 2023, UnitedHealthcare will be modifying our requirements for gastroenterology services. You will be asked to provide advance notification in lieu of prior authorization for gastroenterology endoscopy services for UnitedHealthcare commercial plan members, in accordance with the terms of their benefit plan. Please disregard communications that may reference prior authorization language, as it will take a few weeks for our systems to update to the new advance notification process. Please note that screening colonoscopy procedures are not subject to this advance notification process.
Prescription Drug List
The UnitedHealthcare Prescription Drug List (PDL) provides a list of the most commonly prescribed medications in various therapeutic classes. This list is intended for use with UnitedHealthcare health plans and affiliated companies’ pharmacy benefit plan designs. The PDL applies only to prescription medications dispensed to outpatients and does not include inpatient medications or medications obtained or administered in a physician’s office. The PDL does not define benefit coverage. Benefit coverage is decided by the member’s pharmacy benefit plan. This means that there may be medications listed on the PDL that are not covered under a particular member’s pharmacy benefit plan.
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Temporary Coverage for Drug Shortage - New Alternative Medications Coverage for All Plans
To help address current medication drug shortages, we’ve updated our Prescription Drug Lists (PDLs) for all plans to temporarily cover some therapeutic equivalent and alternative medications.
Important points
- We won’t require prior authorization or step therapy for these alternative medications
- We’ll reevaluate our coverage when any of these drug shortages are no longer in effect and notify you of any changes
- These shortages are according to the U.S. Food and Drug Administration at fda.gov/drugshortages and the American Society of Health-System Pharmacists at ashp.org/drugshortages
Clinical Program Drug Step Therapy – Commercial and Individual Exchange Plans, Also Referred to as UnitedHealthcare Individual & Family ACA Marketplace Plans
Step programs are targeted towards therapeutic classes that have multiple medication options. While clinical effectiveness may be similar among medication options in a therapeutic class, pricing and factors promoting optimal drug use can vary. Step therapy programs require a trial of clinically appropriate alternative(s) before allowing coverage for the Step 2 medications. Prior to the implementation of a step therapy program, there are several components that are incorporated into its development. This includes, if available, an evaluation of peer-reviewed medical literature which includes randomized clinical trials, drug comparison studies, pharmacoeconomic studies, outcomes research data, published clinical practice guidelines, comparisons of efficacy, side effects, potential for off label use and claims data analysis. Review of step therapy also includes a valuation of benefits, risks, and impacts on members. Step programs are submitted to the UnitedHealthcare Pharmacy and Therapeutics Committee, which includes external physicians representing a broad range of specialties and sub-specialties, medical directors and pharmacists for review and approval prior to implementation.
Several states have enacted legislation requiring that step therapy exception requests (also referred to as step therapy override exceptions) must be approved if the member meets certain conditions or situations. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or https://professionals.optumrx.com/prior-authorization.html to determine if you qualify for an exception.
Advance Notification and Clinical Submission Requirements
Advance notification
Advance notification is the first step in determining member coverage based on medical necessity. Prior authorization may still be required.
Clinical submission
Clinical submission requirements may be required for specialties like physical therapy and occupational therapyopen_in_new. This process is handled through Optum and can be initiated on the Optum Provider Portalopen_in_new.
Please see individual plan requirements below for specific requirements.
Updated notice of changes to plan requirements
Services that require advance notification are specified by plan.
- 2023 Summary of Changes to Advance Notification and Prior Authorization Requirements
- 2022 Summary of Changes to Advance Notification and Prior Authorization Requirements
- 2021 Summary of Changes to Advance Notification and Prior Authorization Requirements
Prior Authorization and Notification
Submit, complete and track prior authorizations, determine need for notification, and learn how PreCheck MyScript can help support your practice and your patients by saving time and money on prescriptions.
340B Medicare Advantage Drug Pricing Program
The Health Resources and Services Administration (HRSA) 340B Drug Pricing Program gives 340B-eligible facilities access to federal resources to provide more comprehensive services to eligible patients.
Oncology Medication Clinical Coverage Updates
This policy provides parameters for coverage of injectable oncology medications (including, but not limited to octreotide acetate, leuprolide acetate, leucovorin, and levoleucovorin), including therapeutic radiopharmaceuticals, covered under the medical benefit based upon the National Comprehensive Cancer Network (NCCN) Drugs and Biologics Compendium (NCCN Compendium). The Compendium lists the appropriate drugs and biologics for specific cancers using the US Food and Drug Administration (FDA)-approved disease indications and specific NCCN panel recommendations. Each recommendation is supported by a level of evidence category.
Maximum Dosage and Frequency
This policy provides information about the maximum dosage per administration and dosing frequency for certain medications administered by a medical professional. Most medications have a maximum dosage and frequency based upon body surface area or patient weight, or a set maximal dosage and frequency independent of patient body size.
Medicare Part B Step Therapy Programs
This Medical Benefit Injectable Policy is applicable to most UnitedHealthcare Medicare Advantage plans offered by UnitedHealthcare and its affiliates. Refer to the Plan Exceptions below:
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