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New York | Spring 2016

Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-3210

Important information for health care professionals and facilities

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In This Issue...• A Reminder about Smoking Cessation Codes

• Preferred Drug List Updates

• Health Homes Need Care Providers as Partners

• Prior Authorization Requirement for Functional Endoscopic Sinus Surgery Procedures

• Reviews Help Ensure Members Receive Proper Care

• Member Rights and Responsibilities

• Get Updated Clinical Practice Guidelines

• Reminder to Enroll in Electronic Payments & Statements

• New Helicobacter Pylori Testing Medical Policy

• Case and Disease Management through the Person Centered Care Model

• Site of Service Prior Authorization for Select Outpatient Surgical Procedures

We hope you enjoy the spring edition of Practice Matters. In this issue, you can read about health homes, electronic payments & statements, clinical practice guidelines, and much more. Happy spring!

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33681 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32101

Important information for health care professionals and facilities

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• Prescription or over-the-counter medications, including documentation on the effectiveness of the medication

• Education through pamphlets and/or flyers with quitting tips

The Current Procedural Terminology manual defines behavioral change as: Behavior change interventions are for persons who have a behavior that is often considered an illness itself, such as tobacco use and addiction. Behavior change services may be reported when performed as part of the treatment of condition(s) related to or potentially exacerbated by the behavior or when performed to change the harmful behavior that has not yet resulted in illness.

Behavior change services such as smoking cessation, involve specific, validated interventions of assessing readiness for change and barriers to change; advising a change in behavior; assisting by providing specific suggested actions; and motivational counseling with arranging for services and follow up. Each recommendation, action and result needs to be documented and followed up on at the next visit with additional support or change in the treatment plan as needed.

Preferred Drug List Updates UnitedHealthcare Community Plan’s Preferred Drug List (PDL) is updated quarterly by our Pharmacy and Therapeutics Committee. Please review the changes and update your references as necessary. The list is available at UHCCommunityPlan.com > For Health Care Professionals > New York > Pharmacy Program > PDL Updates.

We also sent a list of alternatives medications to UnitedHealthcare Community Plan members whose current treatment includes a medication that has been deleted from the PDL. Please provide these members with a prescription for a preferred alternative. If a preferred alternative is not appropriate, please call 800-310-6826 to request prior authorization.

Here are updates that took effect Jan. 1, 2016:

A Reminder about Smoking Cessation CodesSmoking cessation counseling codes are used to report behavior change interventions for members who smoke or use some form of tobacco. The codes may be used to report a face-to-face encounter to discuss smoking and tobacco use cessation. The codes are:

• 99406 – Smoking and tobacco use cessation counseling visit; intermediate, greater than three minutes and up to 10 minutes

• 99407 – Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

Smoking cessation codes should be billed only when counseling is actively performed and a supporting treatment plan is developed, managed and updated as needed. Checking off a box at each encounter is not sufficient. Advising the member to stop smoking is not considered smoking cessation counseling and would be included in the regular office visit. Here are examples of an effective treatment plan:

• Enrolling the member in a smoking cessation program

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33682 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32102

Important information for health care professionals and facilities

Brand Name Generic Name CommentsKalydeco granules Ivacaftor Added as alternative for cystic fibrosis. Prior authorization

required. Available through specialty pharmacy.Orkambi tablet Lumacaftor/ivacaftor Added as alternative for cystic fibrosis. Prior authorization

required. Available through specialty pharmacy.Invega Trinza Paliperidone Added as an alternative for schizophrenia. Prior authorization

required.Synjardy tablet Empagliflozin/metformin Added as an alternative for type 2 diabetes mellitus. Step therapy

applies.Cholbam capsule Cholic Acid Added as alternative for bile acid synthesis disorders and

the adjunctive treatment of peroxisomal disorders, including Zellweger spectrum disorders. Prior authorization required. Available through specialty pharmacy.

Zetia Ezetimibe Added as alternative for hyperlipidemia. Prior authorization required.

Vfend* tablet Voriconazole Added as alternative for invasive aspergillosis, candidemia in non- neutropenic patients, esophageal candidiasis, fusariosis and scedosporiosis. Prior authorization required.

Jadenu tablet Deferasirox Added as alternative for chronic iron overload. Prior authorization required. Available through specialty pharmacy.

Prezcobix tablet Darunavir/cobicistat Added as alternative for human immunodeficiency virus (HIV) infection.

Tybost tablet Cobicistat Added as alternative for HIV.Mitigare capsule Colchicine Added as alternative for gout flares and prevention.Zohydro ER capsule Hydrocodone Added as alternative for severe pain management requiring

daily, around- the-clock, long-term opioid treatment. Step therapy applies.

Toujeo SoloStar injection

Insulin Glargine 300 unit/ml Added as alternative for types 1 and 2 diabetes

Striverdi Respimat inhalation

Olodaterol Added as alternative for chronic obstructive pulmonary disease (COPD).

Arcapta Neohaler inhalation

Indacaterol Added as alternative for COPD.

Savaysa tablet Edoxaban Added as alternative for stroke risk reduction, non-valvular atrial fibrillation systemic embolism and for deep vein thrombosis and pulmonary embolism. Prior authorization required.

*Only generics are covered

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PDL Additions

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33683 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32103

Important information for health care professionals and facilities

Brand Name Generic Name CommentsACCU-CHEK Test Strips

ACCU-CHEK Test Strips

PDL alternatives include One Touch Verio test strips and One Touch Ultra test strips. Current users will not be grandfathered.

ACCU-CHEK Glucometers

ACCU-CHEK Glucometers

PDL alternatives include One Touch Verio glucometer, One Touch Ultra 2 glucometer, and One Touch Ultra Mini glucometer. Current users will not be grandfathered.

Vytorin Ezetimibe/simvastatin tablet

PDL alternatives include simvastatin, atorvastatin and Zetia. Current users will be grandfathered.

Lidocaine 5% ointment*

Lidocaine PDL alternatives include lidocaine cream 3%, lidocaine cream 4%, and lidocaine-prilocaine 2.5/2.5% cream. Current users will not be grandfathered.

Colcrys tablet Colchicine PDL alternative Mitigare capsule. Current users will not be grandfathered.Strattera capsule Atomoxetine PDL alternative Guanfacine ER capsule. Current users will be grandfathered.Oxycontin tablet Oxycodone PDL alternatives include morphine sulfate ER tablet, fentanyl transdermal

patch, Zohydro ER capsule, and oxymorphone ER tablet. Current users will be grandfathered.

Nucynta ER tablet Tapentadol PDL alternatives include morphine sulfate ER tablet, fentanyl transdermal patch, Zohydro ER capsule, and oxymorphone ER tablet. Current users will be grandfathered.

Levemir Vials Insulin detemir PDL alternative Toujeo SoloStar. Current users will be grandfathered.Serevent inhalation Salmeterol PDL alternatives include Striverdi Respimat and Arcapta Neohaler. Current users

will not be grandfathered.Foradil inhalation Formoterol PDL alternatives include Striverdi Respimat and Arcapta Neohaler. Current users

will not be grandfathered.*Only generics are covered

If you have any questions, please call the Pharmacy Department at 800-310-6826.

Brand Name Generic Name CommentsLantus Vials Insulin Glargine 100

units/mlStep therapy applies Toujeo SoloStar trial is required. Current users will be grandfathered.

Albenza tablet Albendazole tablet Prior authorization no longer required.Cymbalta* capsule Duloxetine Step therapy removed.Daraprim tablet Pyrimethamine Prior authorization required. Current users will be grandfathered.Intuniv* capsule Guanfacine ER Step therapy removed.

*Only generics are covered

PDL Deletions

PDL Modifications

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33684 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32104

Important information for health care professionals and facilities

Prior Authorization Requirement for Functional Endoscopic Sinus Surgery ProceduresBeginning May 2, 2016, certain functional endoscopic sinus surgery procedures will require prior authorization for many UnitedHealthcare Commercial and UnitedHealthcare Community Plan Medicaid benefit plans, excluding Medicare Dual Special Needs Plans and Medicare Medicaid plans. This requirement was announced in the February issue of the Network Bulletin.

This change is part of our ongoing responsibility to regularly evaluate our medical policies, clinical programs and health benefits compared to the latest scientific evidence and specialty society guidance. Using evidence-based medicine to guide coverage decisions supports quality patient care and reflects our shared commitment to the Triple Aim of better care, better health outcomes and lower costs.

The following functional endoscopic sinus surgery procedures will require prior authorization to evaluate medical necessity in all sites of care:

Procedures CPT CodesNasal/sinus endoscopy, surgical

31237, 31239, 31240, 31254, 31255, 31256, 31267, 31276, 31287, 31288

In previous communications about this requirement, CPT code 31238 was included. Prior authorization will not be required for that procedure code. This requirement is effective for UnitedHealthcare Commercial and UnitedHealthcare Community Plan members for dates of service on or after May 2, 2016 in most states. For details, go to UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Prior Authorization for Functional Endoscopic Sinus Surgery FAQ.

If you have questions, please contact your local Network Management representative or call the provider services number on the back of the member’s UnitedHealthcare ID card.

Health Homes Need Care Providers as PartnersUnitedHealthcare Community Plan would like to partner with care providers to provide educational resources about the benefits of health homes, and how they can improve patient care and reduce over-utilization of emergency rooms.

The health home program was designed by the New York State Department of Health to manage Medicaid’s most vulnerable and chronically ill members. Members assigned to a health home must have two chronic medical conditions or have been diagnosed with a serious mental illness.

UnitedHealthcare Community Plan is working collaboratively with our state partners to assign some Medicaid members to accountable care and health home entities. A health home is a care management model in which all health care professionals communicate with each other regarding all aspects of the patient’s care. The goal is to provide optimal care for the patient in the community to reduce emergency room and hospital utilization for ancillary care.

Health home services support you in providing coordinated, comprehensive medical and behavioral health care support services to members with chronic conditions.

For more information about health homes, please contact Sanrose Russell, Managing Director of Health Homes, at sannrose_russell@uhc.com.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33685 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32105

Important information for health care professionals and facilities

Reviews Help Ensure Members Receive Proper CareUnitedHealthcare Community Plan performs concurrent reviews on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A listing of services requiring prior authorization is available in the Provider Manual.

Decisions regarding coverage are based on the individual benefit plan as well as appropriateness of care and service. We do not provide financial or other rewards to our physicians for issuing denials of coverage or for underutilizing services.

If a service is denied, the treating physician has the right to request a peer-to-peer discussion with the reviewing physician and a copy of the criteria used in the review. Members and practitioners also have the right to appeal denial decisions. Information on requesting an appeal is included in the denial letter.

Appeals are reviewed by a physician who was not involved in the initial denial decision and is of the same or similar specialty as the requesting physician.

Member Rights and ResponsibilitiesThe UnitedHealthcare Community Plan Member Rights and Responsibilities can be found in the Provider Manual. Member Rights and Responsibilities are distributed to new members upon enrollment and then annually.

Get Updated Clinical Practice GuidelinesClinical Practice Guidelines are available at UHCCommunityPlan.com. UnitedHealthcare Community Plan promotes the use of nationally recognized evidence-based clinical guidelines to support practitioners in making decisions about health care. Guidelines are available for diabetes, asthma, perinatal care, preventive services, Attention Deficit Hyperactivity Disorder, depression and many other conditions.

To view a complete list of the most current guidelines, go to UHCCommunityPlan.com > For Health Care Professionals > New York > Clinical Practice Guidelines.

Reminder to Enroll in Electronic Payments & StatementsElectronic Payments and Statements (EPS) is UnitedHealthcare’s solution for electronic remittance advice (ERA) and electronic funds transfer (EFT). It allows you to receive direct deposit of claim payments into your designated bank account(s) and access explanation of benefits (EOBs)/remittance advice online or via 835 ERA files. You can use EPS to access and manage payment information for most UnitedHealthcare health plans. Enrollment in EPS applies to payments from UnitedHealthcare Commercial; UnitedHealthcare Medicare Solutions; UnitedHealthcare Oxford and UnitedHealthcare Community Plan in New York and other states.

You can learn more by:• Visiting WelcometoEPS.com• Watching a short video demo• Attending a live 30-minute webinar for an overview

and answers to questions

Enroll in EPS online or send us a completed enrollment form. If you have questions, please call 866-842-3278, option 5.

Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33686 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32106

Important information for health care professionals and facilities

New Helicobacter Pylori Testing Medical PolicyUnitedHealthcare introduced a new medical policy, effective March 1, 2016 for UnitedHealthcare Community Plan members, for the testing, evaluation and management of dyspepsia and peptic ulcer disease (PUD).

The new medical policy describes the American Gastroenterological Association guidelines stating that serology testing (CPT code 86677) which does not test for an active Helicobacter pylori (H. pylori) infection should no longer be used. Stool antigen test or urea breath test should be used rather than serology testing to both diagnose and confirm eradication of an active H. pylori infection.

H. pylori is a class I carcinogen linked as a causative agent in PUD gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. The medical policy reflects a “test, treat, retest and confirm eradication” policy in cases of H. pylori infection linked to the development of PUD, gastric malignancy and dyspeptic symptoms, instead of moving directly to proton pump inhibitor (PPI) therapy.

UnitedHealthcare developed the H. pylori testing policy from guidelines issued by the American Gastroenterological Association and the American College of Gastroenterology that emphasize:

• Eliminating serology use because studies show that about 50 percent of patients with a positive H. pylori serology do not actually have an active infection (blood tests do not reliably detect active H. pylori infections and are considered investigational)

• Testing, treating and retesting for active H. pylori infection before prescribing PPI

UnitedHealthcare’s medical policy and information on the recommended tests can be found at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Policies > UnitedHealthcare Community Plan Medical Policies and Coverage Determination Guidelines > Helicobacter Pylori Serology Testing.

If you have any questions, please contact your Provider Advocate.

Case and Disease Management through the Person Centered Care ModelUnitedHealthcare Community Plan’s Person Centered Care Model (PCCM) is a holistic approach to care, case and disease management for members with complex needs. Medical, behavioral, social and environmental needs are addressed through the coordination of physicians, hospitals and community services. Through the program, we seek to:

• Engage with primary care physicians and other health care professionals and key partners to expand access to quality health care so our members can get the care they need.

• Support the physician/patient relationship by facilitating regular appointments, removing barriers to care and helping to ensure members see their physician on a regular basis.

• Provide the treating physician a direct link with UnitedHealthcare Community Plan to best facilitate the ongoing care and treatment of the member within the benefit structure available to the member.

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33687 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32107

Important information for health care professionals and facilities

What are some of the things the PCCM program can provide members?

• Develop and monitor an individualized care plan by telephonic or face-to-face contact.

• Help them understand and manage their condition, including self-monitoring and medical testing.

• Improve adherence to treatment plans and medication use.

• Reduce unnecessary hospital admissions and emergency room visits related to complications of the disease and its treatment.

• Improve coordination of care by providing information about the member’s condition to caregivers who have the member’s consent.

• Help effectively manage their conditions and comorbidities, including depression, cognitive deficits, physical limitations, health behaviors and psychosocial issues.

• Provide additional resources as appropriate.

Areas of expertise:• Asthma• Coronary Artery Disease • Chronic Obstructive Pulmonary Disease • Diabetes• Congestive Heart Failure • Maternity

Site of Service Prior Authorization for Select Outpatient Surgical ProceduresProviding access to medically necessary care while improving cost efficiencies for the overall health care system is critical as we work toward achieving the Triple Aim to improve care experiences, health outcomes and total cost of care for UnitedHealthcare members.

In support of that work, for dates of service on or after May 2, 2016 we will expand site of service-based prior authorization guidelines to include

UnitedHealthcare Community Plan Medicaid members in New York. This requirement was announced in the February 2016 Network Bulletin. It does not apply to Medicare Dual Special Needs Plans (DSNPs) and Medicare Medicaid Plans (MMPs).

Under these guidelines, prior authorization is required to perform certain surgical procedures in an outpatient hospital setting. No prior authorization is required for these procedures if they are performed at a network ambulatory surgery center. Coverage determinations take into consideration the availability of a participating network facility, specialty requirements, physician privileges and whether a patient has an individual need for access to more intensive services.

For dates of service on or after May 2, 2016, you must submit prior authorization requests to perform the following procedures in an outpatient hospital setting:

Procedures CPT CodesAbdominal Paracentesis

49083

Carpal Tunnel 64721Cataract 66821, 66982, 66984Gynecology 57522, 58565, 58353, 58558, 58563Hernia Repair 49585, 49587, 49650, 49651, 49652,

49653, 49654, 49655

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Practice Matters: TX - Summer 2013 Customer Service Center: 888-362-33688 Practice Matters: NY - Spring 2016 Provider Services Center: 877-842-32108

Important information for health care professionals and facilities

Procedures CPT CodesLiver Biopsy 47000Tonsillectomy & Adenoidectomy

42820, 42821, 42825, 42826, 42830

Upper & Lower Gastrointestinal Endoscopy

43235, 43239, 43249, 45378, 45380, 45384, 45385

Urologic 50590, 52000, 52005, 52204, 52224, 52234, 52235, 52260, 52281, 52310, 52332, 52351, 52352, 52353, 52356, 57288

To help ease this transition, we encourage you to familiarize yourself with network ambulatory surgery centers in your area and obtain privileges to perform procedures in those settings, if you do not already have them.

Prior authorization requests can be filed in multiple ways:• Log in to UnitedHealthcareOnline.com to use the

Eligibility & Benefits application on Link or go to Notifications/Prior Authorizations > Notification/Prior Authorizations Submission. Online submission is the easiest and recommended method for submitting prior authorization requests.

• Call the Provider Services number on the back of your patient’s member health care ID card.

• Fax the request to 866-950-4490.

If you do not complete the prior authorization process before performing these procedures in an outpatient hospital setting, claims will be denied. Members cannot be billed for services that are denied due to lack of prior authorization.

For more information on this requirement, please see the answers to frequently asked questions at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Protocols > Site of Service for Outpatient Surgical Procedures FAQ.

If you have questions, please contact your local Network Management representative or call the Provider Services number on the back of the member’s ID card.

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Practice Matters is a quarterly publication for physicians and other health care professionals and facilities in the UnitedHealthcare network.

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