UnitedHealthcare announced that it will require prior authorization on medications under the Medicare Advantage Part B Step Therapy Program starting Jan. 1, 2025. It has lined up an effective move to manage the utilization of targeted high-cost drugs and ensure that patients try the preferred treatments before using the costlier alternatives.
This new policy rules that step therapy requirements will be only applicable to new member enrollment. However, the existing member definition applies to individuals who had a claim within 365 days on a non-preferred drug. Members with clinical documentation showing continued use of the drug are not bound by this rule.
The UnitedHealthcare Medicare Advantage, UnitedHealthcare Dual Complete, Peoples Health, and Preferred Care Partners of Florida plans would be affected. A complete listing of denied plans and medications is available in the official Medicare Part B Step Therapy Program Policy.
There should be prior authorization requests through standard protocols that providers will submit. This includes plans where utilization management has been delegated to medical groups or IPAs. Providers can easily access the prior authorization process via UnitedHealthcare Provider Portal using their One Healthcare ID on a form that is submitted under categories like "Specialty Pharmacy" or "Oncology." All clinical information about the patient must be submitted on all claims to avoid delays or denials.
UnitedHealthcare assures standard processing for prior authorization requests for Part B drugs within 72 hours and expedited ones within 24 hours. Providers will be notified of the decision and of any rights they may have to appeal.
If you seek more information, visit UnitedHealthcare Provider Portal. You will find UnitedHealthcare online 24/7 or connect via telephone at 888-397-8129.
Check out the list of medications included in the Part B Step Therapy Program.
This shift represents the latest steps in optimizing medication use on the part of UnitedHealthcare under Medicare Part B toward efficiency without compromising on high standards of patient care.
DentaQuest USA Insurance Company, Inc. will limit new General and Pediatric Dentists to the Texas Medicaid network effective 15 October 2024. The constriction will be in many counties, including Dallas, Fort Worth, Harris, Jefferson Counties, and other counties in Texas. This is intended to create sufficient network adequacy while managing provider capacity for Medicaid members in these regions.
The counties included are:
Under the new policies, more General and Pediatric Dentists will be added to the network to fill in the gaps for providers who left practice within 30 days. All applications by new providers or provider groups will be accepted only with a defined need in the network. DentaQuest will continue processing regular business updates for current providers: provider relocations or practice changes, but there will be no expansion that is not justified.
These exclusions only apply to Medicaid General and Pediatric Dentists in Texas, leaving all other provider applications unscathed - specialists, Medicare, CHIP, and other commercial plans are not affected by these changes.
DentaQuest will cap new providers, including General and Pediatric Dentists so that coverage will be available for Medicaid members, and it always maintains parity in the network regarding the number of providers involved.
Through optimal utilization of networking, it will continue servicing its existing Medicaid members and providers.
The providers based in the affected areas should consider their current practices and level of staffing, given the new provisions. Other than those referred to above would not be accepted except for demonstrable needs.
Providers who need more information about these changes can approach DentaQuest to seek out the specifics of such changes and how they can influence their practices.
On January 1, 2025, UnitedHealthcare will launch Individual Exchange plans in four new states, while continuing to offer these plans in the 26 states where they are currently available. Additionally, thirteen of the existing states will see expanded access, covering 119 new counties.
New States for 2025:
Existing States:
As of January 1, 2025, the Rocky Mountain Valley and Rocky Mountain Sky health plans, along with their respective provider networks, will merge and expand into additional counties. The newly combined network will be named Rocky Mountain Valley.
Prior Authorization Information: Providers in the new states should review the list of codes that require prior authorization.
Preparing for the New Plans: To ensure readiness for 2025, providers are encouraged to visit the Individual Exchange plans page, which offers access to:
Additional Preparation Recommendations:
For further assistance, please go to the Individual Exchange plans page, call a provider advocate or chat live with the representatives anytime through the UnitedHealthcare Provider Portal.
As of January 1, 2025, prior authorization requirements and criteria for UnitedHealthcare radiation will be implemented on Rocky Mountain Health Plans.
These changes will affect the following Rocky Mountain Health Plans:
Radiation Prior Authorization/Notification Requirements: The plans will require prior authorization/notification for the following radiation therapy services:
The corresponding codes include:
|
RadOnc 40 Dx codes |
|||
| G6001 | G6011 | 77014 | 77401 |
| G6002 | G6012 | 77331 | 77402 |
| G6003 | G6013 | 77370 | 77407 |
| G6004 | G6014 | 77371 | 77412 |
| G6005 | G6015 | 77372 | 77470 |
| G6006 | G6016 | 77373 | 77520 |
| G6007 | G6017 | 77385 | 77522 |
| G6008 | S2905/55874 MR only | 77386 | 77523 |
| G6009 | G0339 | 77387 | 77525 |
| G6010 | G0340 | 77399 | 79445 |
This change is in addition to the existing requirements for intensity-modulated radiation therapy and proton beam therapy.
Optum® will manage these prior authorization requests through the Cancer Guidance Program. For more information, refer to the Comprehensive Radiation Therapy Management — Training for Prior Authorization Request Submissions interactive guide.
How to Submit a Radiation Oncology Prior Authorization Request
To submit a request, follow these steps through the UnitedHealthcare Provider Portal:
For any inquiries, please email rmhp_updates@uhc.com.
The Centers for Medicare & Medicaid Services (CMS) recently issued broad new guidance to assist states in making sure children in Medicaid and CHIP receive their required Early and Periodic Screening, Diagnostic, and Treatment. As of May 2024, an estimated 38 million children are enrolled in Medicaid and CHIP, many of whom are eligible for EPSDT services covering a wide range of physical and behavioral health service needs.
Three areas that it focuses on in terms of improving the access of children to EPSDT services are:
Towards this end, CMS encourages states to engage families more effectively with their benefits and to support better coordination of care for children. The rule further asks Medicaid-managed care plans to provide all services needed by eligible children, including transportation to health care appointments.
Workforce concerns are addressed by strategies that recommend expansion of qualifications among providers, increase interprofessional consultation, and enhance the use of telehealth. CMS encourages states to pursue financial incentives for physicians to deliver high-quality care to children.
The third issue suggests expanding services offered to children with behavioral health needs. These include such provisions as access through one point of entry to care and comprehensive covered community-based services.
Overlooks will include dedicated attention to foster children as well as those with disabilities, with CMS reminding states that its coders are expected to cover all medically necessary care.
CMS explained that this guideline marks the first of the most comprehensive updates made on EPSDT in the last decade and places a great emphasis on its role in addressing issues about mental health and promoting health equity among poor children.
Centers for Medicare & Medicaid Services (CMS) announced that accelerated and advanced payments are available to the Medicare fee-for-service providers and suppliers affected by Hurricane Helene. This is on the grounds of an emergency declaration created by the Secretary of the United States Department of Health and Human Services in collaboration with the FEMA to assist healthcare facilities overcome financial constraints in FEMA-declared disaster zones caused by the declarations made by the President.
Providers and suppliers are facing a huge cash flow challenge because of the disruption resulting from the hurricane. Under this policy, providers of Medicare Part A and suppliers of Part B can receive accelerated or advanced payment as early as October 2, 2024. The sum issued would depend on the percentage of claims payments covered in the previous 90 days. This process of repayment will automatically occur through Medicare claims for the next 90 days and the balance shall be demanded after day 91.
These benefits will be made only to enrolled Medicare providers and suppliers that satisfy certain conditions. They must have filed at least one claim successfully within the preceding 90 days of the date of the incident and be classified as in good standing with Medicare.
Moreover, CMS provides the flexibility of extending the currently available ERS. Those providers who have a 60-month maximum term for ERS are allowed to adjust their payment, but those providers who have shorter terms of ERS can extend their scheduled terms by two months.
Providers and suppliers may also ask that demand letters from overpayment be rescinded and reissued in case the mailing service is interrupted causing difficulties in receiving such notifications.
For additional help, you can contact a Medicare provider's assigned Medicare Administrative Contractor (MAC). More information can be found on the CMS website.
You can find a list of Medicare Administrative Contractors (MACs) at the CMS.gov website at: https://www.cms.gov/mac-info.
Effective immediately, the UnitedHealthcare Community Plan of New Jersey has implemented a new requirement in compliance with state Medicaid guidelines for sterilization procedures. All healthcare providers submitting claims for sterilization procedures—including hospitals, operating physicians, anesthesiologists, and clinics—must attach a fully completed Consent Form-7473-M ED 3-81 to their claims. Failure to comply will result in denied payments.
The consent form is to be attached to support each sterilization procedure to ensure that such has been authorized and consented to by the patient, with federal and state requirements. It must be followed for paper and electronic claim submissions.
Providers who mail paper claims must have the completed form actually attached to their documentation. For electronic submissions, providers must follow the protocols of their respective clearing houses to attach the consent form to the claim file.
Providers should be aware that when partial forms are submitted or the form is missing, it can cause delays or denials of payments which may impact the time to reimbursement of services. UnitedHealthcare therefore advises all providers to familiarize themselves with these procedures as a way of not facing the interruptions.
UnitedHealthcare 24/7 further assistance through Provider Portal includes real-time options that are available in chat, and providers may contact Provider Services toll-free at 888-362-3368, Monday through Friday, 8 a.m. through 6 p.m. Eastern Time, for business hours. More detailed information can be found on the UnitedHealthcare page.
UnitedHealthcare has made the decision that starting October 1, 2024, it will no longer accept demographic updates by email or on the Demographic and Practice Change Request Form from groups and individual providers.
Practitioners are reminded to use one of the three other permitted ways of submitting to ensure current demographic information and minimal disorganization.
Common Submission Methods
Providers will need to provide updates through just one of the above methods. It will, therefore eliminate the duplication of data submissions and possible clarifications.
Non-submission of data through any of the foregoing methods will have a potential impact on inaccuracies in provider directories that affect their patients and delayed payment claims.
Implications for Medicaid Providers
Medicaid contract providers will continue to use their states' mandated processes to report demographic data. Such data will also need to be reported via one of UnitedHealthcare's accepted methods to ensure uniformity in the system.
To learn more, the provider has been advised to visit UnitedHealthcare's data attestation page or contact through the 24/7 live chat feature within the UnitedHealthcare Provider Portal.
This is a policy change the company continues to focus on a reduction in administrative burden and adequate provider information critical for improvement.
Recording consent to submit immunization information to the Texas Immunization Registry (ImmTrac2), by healthcare providers in Texas should be made to improve the quality of care and more up-to-date vaccine records. The goal for this is to make access to records of immunizations easier for healthcare professionals, schools, and parents while further maximizing quality scores and earnings for providers.
Now healthcare providers can seek the immunization records consent from a child's parent or legal guardian. Hence, the child's lifetime immunization records are submitted to ImmTrac2, and the record is kept for extended periods. These records are a must in such instances, including school enrollment, travel, and change in healthcare providers.
The advantages of ImmTrac2 are:
A provider must obtain, in an ImmTrac2 Minor Consent Form (C-7), a completed, dated, and signed form by a parent, legal guardian, or managing conservator to enroll children 17 years of age and younger. The provider is responsible for entering the consent status into ImmTrac2 when consent is received, then, the original consent form must be kept on file in the patient's chart.
A healthcare provider can refer to pages 119-120 of the ImmTrac2 User Manual for more information on recording consent in ImmTrac2. Providers should also obtain training materials directly from the Texas DSHS to ensure proper compliance.
For any questions about ImmTrac2, contact Texas DSHS at 800-348-9158 or by email at ImmTrac2@dshs.texas.gov. To see the Contact Us page for more information, click here. UnitedHealthcare Provider Portal may also be contacted at any time of the day.
The Colorado legislation that went into effect August 1, 2024, changed the disclosures mental health providers were required to make to their clients under state law. The new law is a reminder to providers of mental health services in Colorado to update their patient disclosure notices. In Colorado, a mental health provider must give specific information in writing when the client is first in contact with them. It applies to a variety of mental health professionals: psychologists, social workers, marriage and family therapists, licensed professional counselors, addiction counselors, and licensee candidates.
Mandatory disclosure includes:
Colo. Rev. Stat. Ann. § 12-245-216(1)
The new law significantly narrowed how much information had to be disclosed. Previously, the Colorado statute mandated information about levels of regulation that apply to various mental health professionals be included by providers. Still, this requirement was eliminated by Senate Bill 2024 Colo. Legis. Serv. Ch. 217 (S.B. 24-115). That makes it good for providers since some of the disclosures have been rolled back here.
