Archives: Newsletter

For UnitedHealthcare Individual Exchange plans (also called Individual & Family ACA Marketplace plans), prior authorization is required for total joint replacement procedures. Providers requesting these procedures (CPT codes 27445, 27447, 27130, and 27132) due to osteoarthritis may need to submit additional medical documentation. This applies nationwide, and no new codes are being added to the… Continue reading New IFP Rule: Now Requires Medical Records for All Hip and Knee Surgeries

The Ohio Department of Medicaid website provides guides, past webinars, and answers to frequently asked questions regarding the EVV system for providers to access. Current preparations by healthcare providers will help prevent future claim problems while maintaining compliance with state and federal requirements. UnitedHealthcare introduced electronic submission of unsolicited claim attachments as a new business… Continue reading UnitedHealthcare Expands EDI 275 Claim Attachment Options

UnitedHealthcare Community Plan requires all Ohio home health providers who work with them to establish EVV system access through Sandata beginning June 1, 2025. The state-wide implementation supports the 21st Century Cures Act by working to enhance home- and community-based service quality through increased accountability. Home health providers risk denial of claims for their home… Continue reading Ohio Providers Must Use EVV Platform to Avoid Claim Denials for Home Health Services

UnitedHealthcare Community Plan in New York adjusted the process of getting referrals for Medicaid beneficiaries under its system. It works towards simplifying patient care access while minimizing administrative work for health providers. Specialty services now require no referral from primary care providers for their main condition for care. Most UnitedHealthcare Community Plan New York Medicaid… Continue reading UnitedHealthcare Updates Referral Policy for New York Medicaid Members

The Centers for Medicare and Medicaid Services (CMS), through their official announcement on April 17, 2025, extended the necessary off-cycle revalidation deadline for skilled nursing facilities (SNFs). The revised deadline demands SNFs to finish their revalidations together with an updated Attachment 1 instead of Form 855A Sections 5 and 6 before August 1, 2025, while… Continue reading CMS Extends SNF Off-Cycle Revalidation Deadline to August 1, 2025

For Providers of UnitedHealthcare Community Plan in New York Important Notice: When submitting claims for prenatal or postpartum services, include a Category II CPT code alongside global or bundled billing codes. Use one of these Category II codes as appropriate: 0500F: First prenatal appointment 0502F: Follow-up prenatal appointment 0503F: Postpartum appointment Purpose of Category II… Continue reading NY Medicaid: Category II CPT® Codes Required for Prenatal and Postpartum Services

Starting January 1, 2025, the criteria for follow-up after emergency department visits for mental health (FUM) will expand to include additional diagnoses, potentially requiring members to schedule follow-up appointments. Members seen in the emergency department for substance use (FUA) will also need follow-up care. Both medical and behavioral health care providers can utilize appropriate billing… Continue reading Action Required: Update Billing and Diagnostic Codes to Close FUM/FUA Gaps

Medicare provider enrollment policies received substantial revisions from the Centers for Medicare & Medicaid Services (CMS) during this spring season, which both reinforced established requirements and added new clarification methods to minimize enrollment challenges and waiting times. The April 3, 2025, MLN newsletter published by CMS reaffirmed the need for providers to report “managing employees”… Continue reading CMS Spring 2025 Provider Enrollment Key Policy Changes & Updates

The updated guidelines for the Follow-Up After Emergency Department Visit for Mental Illness (FUM) measure will expand the included mental health diagnosis criteria starting January 1, 2025. The expanded FUM measure will cause more patients to need clinical follow-up after emergency room treatment. Healthcare providers should schedule timely follow-up appointments for substance use disorder patients… Continue reading UHC: New Billing Code Updates to Close FUA & FUM Quality Gaps

Ohio established a new claims submission policy starting May 1, 2025, that mandates all Ordering Referring and Prescribing (ORP) health care professionals to possess a valid National Provider Identifier (NPI). UnitedHealthcare Community Plan of Ohio has stated that they will deny claims that lack an NPI number for ordering, referring, and prescribing professionals as per… Continue reading UHC Ohio Medicaid: New ORP Claim Denial Policy Announced