On January 1, 2025, Optum Rx will start managing prior authorization and step therapy requests for prescription drugs for members of the plan offered by Golden Rule Insurance Company in certain states, in an effort to make the process more streamlined using UnitedHealthcare's clinical criteria for the prescription benefit management of those clients.
This change applies to:
Streamlined Prior Authorization Requests
Optum Rx also provided providers with another two avenues for requesting prior authorizations: Online submissions at the Prior Authorization for Prescribers webpage, and call requests made through Optum Rx's prior authorization department at 800-711-4555. Now, this may help streamline submittals across different avenues, thus perhaps making provider approvals easier.
Real-Time Benefit Checks with PreCheck MyScript
Prescribers can also take advantage of the services offered by PreCheck MyScript, a digital benefit tool, to check coverage and pharmacy benefits for the UnitedHealthcare member. Using the feature, prescribers can rapidly run pharmacy trial claims and obtain information regarding coverage that can help inform the decision-making process to ensure patient care is appropriately directed.
The UnitedHealthcare Community Plan of New York will no longer cover CPT® code 82652, which corresponds to Vitamin D, 1,25-dihydroxy testing. This follows the policies established by New York State Medicaid since this code will not be covered through Medicaid services. Providers should note that all claims submitted for services using this code on or after November 1 will be automatically denied.
This addition to the non-covered list means Vitamin D testing for Medicaid recipients who are enrolled in New York in the UnitedHealthcare Community Plan will not be covered. Providers and facilities should change their billing habits and inform patients appropriately regarding this change.
Providers needing more comprehensive support are encouraged to visit UnitedHealthcare’s Contact Us page, where additional contact options are provided.
Starting December 1, 2024, in Colorado, Nevada, and New Mexico, Optum Health Networks will receive prior authorization requests and inpatient notifications only through a secure online electronic system. This is just one way this change should enhance efficiency over fax submissions in general and allow for much more prompt response times over paper submissions.
This requirement will apply to all healthcare providers who have patients within the states that have their network management under Optum. Patients eligible to access this network will have member ID cards with the payer ID "LIFE1." Providers are encouraged to scrutinize patient ID cards in order to determine a patient's eligibility for use of this new online-only submission process.
Health professionals who already possess an Optum Pro account login using One Healthcare ID and their password and go to the Medical Management tab within the Optum Pro portal. For unregistered providers, they can easily register for an Optum Pro portal website, or even just get a One Healthcare ID from identity.onehealthcareid.com.
This will decommission several fax numbers that had been used for submissions and notices across the three states. The fax numbers available for prior authorizations have been 888-992-2809, whereas for Medicare Part B 855-221-1978 will no longer be available. Other specific fax numbers in Nevada, New Mexico, and Colorado for inpatient notifications, clinical information, and appeals will no longer be available.
Optum has stated that there is a requirement for notification of admission within one business day, and notices of Medicare Non-Coverage should adhere to the new online submission guidelines. Exceptions to this online mandate apply only where legally required to accept faxed documents.
This update is in line with the larger digital-first initiative at Optum for enhanced efficiency through healthcare networks. Learn more here: optumproportal.com.
UnitedHealthcare Community Plan of Missouri, together with the Missouri Department of Social Services, has launched the Missouri Medicaid Audit & Compliance Provider Communications Portal. It is an initiative for improving communication and reducing service complexity through collaboration. It will establish a safe electronic means of communicating with the entire state's network of healthcare providers.
The portal would ease the administration of the providers. There will be streamlined features available for providers to update contact information, submit forms and documents, and even file complaints or fraud referrals anonymously. The platform will also ease the submission of required quarterly and annual reports, the submission of questions, and the electronic upload of vital documentation in an effort to reduce delays and paperwork.
One important feature that will be beneficial to providers is the portal's ability to communicate. Providers can receive targeted e-mails tailored to their specific practice needs and SMS text messages for timely alerts, including courtesy reminders for essential due dates, such as report submissions and Medicaid revalidations.
The portal also offers a highly detailed FAQ page, thus enabling service providers to readily access the information they need; hence, they will not have the hassle of coming back to seek additional help. A secure exchange of information means that the MMAC portal is a convenient way for healthcare providers can interact with Missouri Medicaid on quality and transparency across the services.
Healthcare providers and stakeholders can learn more about the new platform by visiting the Missouri Medicaid Audit and Compliance website.
This most recent program demonstrates Missouri's commitment to improving the delivery of services through modernized communication and digital resources, creating an environment conducive to more efficiency in the delivery of Medicaid services throughout the state.
On October 21, 2024, the Departments of Health and Human Services, Labor, and Treasury proposed new rules titled “Enhancing Coverage of Preventive Services Under the Affordable Care Act.” These rules aim to improve access to cost-free preventive services in the commercial market, focusing on reducing barriers to contraceptive coverage, including over-the-counter options.
Background
The Affordable Care Act (ACA) introduced section 2713 of the Public Health Service Act (PHS Act), requiring non-grandfathered group health plans and insurers to cover specific recommended preventive services without cost-sharing. These services include:
The Departments' regulations under PHS Act section 2713 allow plans and issuers to apply reasonable medical management techniques to determine the coverage of preventive services not specifically outlined in guidelines. They must cover, without cost sharing, essential items and services for recommended preventive services.
Since the ACA's enactment in 2010, the Departments have received many complaints regarding coverage of certain preventive services. Currently, OTC preventive services are covered without cost-sharing only when prescribed by a healthcare provider. In October 2023, the Departments sought public input on requiring OTC preventive products, including contraception, to be covered without a prescription.
In response to RFI feedback, ongoing complaints, reports of inadequate contraceptive coverage, recent Executive Orders, and the FDA's July 2023 approval of a prescription-free progestin-only oral contraceptive. Further, the Departments are proposing amendments to regulations on preventive service coverage and communication to participants and enrollees.
Summary of Proposed Rules
Exceptions Process for All Recommended Preventive Services
The Departments plan to formalize existing guidance on how plans and issuers can use reasonable medical management techniques. The proposed rules would require these plans to create a clear and easy exceptions process. This process would allow individuals to get coverage without cost sharing for preventive services that their healthcare provider determines are necessary. This applies even if the services are not typically included in their health plan's coverage. This ensures that medical management does not create unfair barriers to accessing preventive services under section 2713 of the PHS Act.
Contraceptive Coverage and Disclosure
The proposed rules would require plans and issuers to cover recommended over-the-counter (OTC) contraceptive items without needing a prescription and without cost-sharing. Currently, the guidance states that OTC preventive health items, like folic acid and some contraceptives, must be covered without cost only when prescribed by a healthcare provider. However, section 2713 of the PHS Act and current HRSA-supported Guidelines do not require a prescription for OTC contraceptives to be covered without cost sharing. Should this proposal be implemented, coverage will comply with the law; prescription needs and out-of-pocket expenses will have been removed to increase access to contraceptives among women.
To facilitate implementation and to gather feedback on these policies, the Departments propose a staged approach for addressing recommended preventive service OTC medications, beginning with contraception. This focus responds to the ongoing debates regarding consumer out-of-pocket expenses for contraceptive items and services.
The proposed rules would require plans and issuers to cover certain recommended contraceptive drugs and drug-led combination products without cost-sharing unless at least one therapeutic equivalent is already covered without cost. The Departments will also define "therapeutic equivalent" and "drug-led combination" products according to FDA standards.
The proposed rules would require plans and issuers to include a disclosure in the results of any transparency in coverage self-service tool, stating that over-the-counter (OTC) contraceptive items are covered without a prescription and without cost sharing. This disclosure would also give out a phone number and a website link where participants can find out more about the contraception coverage in their plan.
Such rules would not alter the federal conscience protection of contraceptive coverage for employers, plans, or issuers. The Departments have asked for views on whether the contraceptive coverage proposals should apply to other preventive services as recommended. They intend to shortly float a new NPRM to specifically deal with other aspects of coverage of all preventive services.
Applicability Dates and Comment Period
The Departments propose that the requirement to provide an exception process for all recommended preventive services will take effect when the final rules are published. The specific proposals related to contraceptive coverage—including the OTC contraception coverage, therapeutic equivalence, and transparency in coverage disclosures—would apply to plan years (or policy years in the individual market) starting on or after January 1, 2026.
To be considered, written comments must be submitted within 60 days of the publication date in the Federal Register. For more information on the proposed rules, visit the Federal Register.
A substantially revised version of Form CMS-855A was issued by the Centers for Medicare & Medicaid Services (CMS). According to the new guidelines, skilled nursing facilities will be expected to use the revised form for all initial enrollment, revalidation, reactivation, and changes of ownership applications. The new form is effective for SNFs as of October 1, 2024.
Requirements for Skilled Nursing Facilities in Form CMS-855A
Reporting Requirements for ADPs
CMS identified some categories of entities and individuals that must be reported under Attachment 1, provided that they qualify as ADPs. Some of those categories are as follows:
CMS has also reemphasized timely and accurate reporting. New or updated SNF Attachment 1 information shall now be reported within 30 to 90 days of any changes.CMS announced off-cycle Medicare revalidation for SNFs, scheduled to occur between October and December 2024. These updates signify continuous efforts by CMS to increase transparency and oversight at SNFs.
For further information, SNFs should consult CMS’ official guidance on the updated Form CMS-855A and prepare for the upcoming off-cycle revalidation process, which is expected to take place through the end of 2024.
In efforts to heighten security and reduce the opportunities for Medicare fraud, CMS announced that it was requiring all Medicare Administrative Contractors, including NGS, to eliminate the provider and beneficiary eligibility telephone number functionality from their IVR system. Certified home health agencies and hospices that had used this system to acquire eligibility data through November 18, 2024, would no longer be allowed to do so.
Elimination will affect other important pieces of information previously available through IVR Option 1, such as eligibility dates for Part A and Part B, current and prior year deductibles, amounts for physical and occupational therapy limits, and information regarding home health and hospice providers. Also, the information related to preventive care, that was previously accessible using the IVR.
In order to retain access to such information, NGS encourages providers to utilize the secure online portal, NGSConnex. CHHAs and hospices that are not currently enrolled in NGSConnex are encouraged to start the enrollment process by referring to the appropriate NGSConnex User Guide.
NGS is offering several webinars that will assist providers in navigating the NGSConnex portal to locate provider registration, look up a beneficiary's eligibility, and more. The NGS Connex webinars are located on the NGS site under Education and are easily accessible by selecting "Jurisdiction 6 Home Health & Hospice (HH&H)".
NGS has announced that their Provider Contact Center (PCC) will discontinue eligibility through telephone. The reasons include that contacts cannot disclose information obtained from self-service features like NGSConnex. For more information and to enroll in the webinars go to NGSMedicare.com.
The Biden-Harris Administration recently approved Section 1115 demonstration amendments that have granted Medicaid and CHIP permission to be utilized in conjunction with conventional healthcare services practiced at Indian Health Service, Tribal facilities, and urban Indian organizations. This historic step has been announced by the U.S. Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS). The aim is to improve access to care and strengthen patient outcomes for the American Indian and Alaska Native populations in Arizona, California, New Mexico, and Oregon.
HHS Secretary Xavier Becerra explained the importance of the expansion. According to him, traditional healthcare practices are of great importance to American Indian and Alaska Native populations. Also, with Medicaid and CHIP, we're extending access to culturally appropriate, high-quality health care in Tribal communities.
CMS Administrator Chiquita Brooks-LaSure noted that this is part of the work of the Biden-Harris Administration in addressing health disparities and equity. In taking care improvement to heart, the approvals of the amendment include what has long been needed in Tribal communities, it re-integrated into care.
There, in Washington, IHS Director Roselyn Tso supports and acknowledges that it was indeed traditional healing knowledge that has been a vital factor in maintaining health in American Indian and Alaska Native communities for generations. She said the administration recognizes the value of those practices bridging culture, science, and wellness.
Under this shift in policy, several health disparities that have been prevalent among the Indigenous peoples will be solved. Indigenous peoples have higher percentages of obesity, diabetes, mental illnesses, and substance abuse disorders. This can be considered a step toward health equity among tribal communities since traditional healing practices will be covered under Medicaid and CHIP.
Learn more about state approvals at Medicaid.gov.
Arizona Health Care Cost Containment System (AHCCCS)
California Advancing and Innovating Medi-Cal (CalAIM)
New Mexico Turquoise Care
Oregon Health Plan (OHP)
Starting Dec. 1, 2024, you’ll be required to submit medical pre- and post-service appeals and disputes electronically. This change affects most* network healthcare professionals (primary and ancillary) and facilities that provide services to UnitedHealthcare Community Plan (Medicaid) members in Arizona.
If you use an outside vendor, such as a revenue cycle management company, please ensure they’re aware of the following changes and digital workflow options.
Use the Prior Authorization and Notification tool through the UnitedHealthcare Provider Portal:
Here are two ways to access UnitedHealthcare's services:
Option 1: UnitedHealthcare Provider Portal
Option 2: Application Programming Interface (API)
For more details, visit the UnitedHealthcare Provider Portal.
New consumer protection laws would go into effect on October 20, 2024, in all of New York State and should impact providers of healthcare dramatically. The laws were contained in the FY 2025 Executive Budget to safeguard patient rights concerning consent to receive service and pay for it as well as the utilization of credit cards in medical bills.
Separate Consent for Payment and Services Under Public Health Law Section 18-c One of the important changes is the use of Separate Consent for Payment and Services. This ensures patient consent for treatment must be different from consent to pay for any of the medical services. Previously most providers used to put both into one consent form.
The new law also prevents the providers from getting consent for payment until after the service has been performed and the cost has been discussed with the patient. According to reports, the New York Department of Health would further detail how this law must be carried out. Failure to do so makes them susceptible to fines, which may reach a high of $2,000 per violation.
Another highly relevant alteration contains Prohibitions on Applications for Medical Financial Products under General Business Law Section 349-g. A healthcare provider or its employees are forbidden to assist in any way a patient may use an application for medical loans or credit cards, which are exclusively designed to pay any healthcare cost. That way, a patient will fill out the applications so that they will not be influenced and misguided. Violations can be liable for a fine of $5,000 every time.
In addition, Section 519-a of General Business Law gives Credit Card Preauthorization Restrictions. The provision prohibits providers from requiring patients to have credit cards on file and from offering preauthorization before providing medically necessary or emergency services. Providers must also apprise the patient of the risks of having his credit card exposed to medical payments that may result in losing state and federal protections regarding medical debt.
By the October 20 deadline, healthcare providers are supposed to review and update their policies to avoid penalties. In the next few weeks, there will be additional clarifications on regulatory requirements.
