Changes to Existing Reimbursement Policies

Changes to Existing Reimbursement Policies – Effective May 17, 2014

Effective for claims processed on or after May 17, 2014, UnitedHealthcare Community Plan will make changes to the following reimbursement policies:

 Professional/Technical Component Policy  Supply Policy

Professional/Technical Component Policy

According to the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual, drug administration codes CPT 96360-96379, 96401-96425 and 96521-96523 are considered included in the facility payment when reported in ambulatory surgery center (ASC) place of service (POS) 24. Additionally, the CMS National Physician Fee Schedule guidelines advise that payment should not be recognized for Professional/Technical Component (PC/TC) Indicator 8 codes, which are defined as physician interpretation codes furnished to patients in the outpatient or non-hospital setting.

To better align with CMS, UnitedHealthcare Community Plan will deny drug administration codes CPT 96360-96379, 96401-96425 and 96521-96523 reported by a physician or other health care professional in a POS 24. UnitedHealthcare Community Plan will also deny PC/TC Indicator 8, CPT code 85060, when reported by a physician or other health care professional with a POS code other than inpatient hospital (POS 21).

Supply Policy:

To align with the CMS Prospective Payment System (PPS) methodology related to reimbursement of supplies in a facility POS, UnitedHealthcare Community Plan will deny the purchase of certain durable medical equipment (DME), orthotics, prosthetics, drugs and biologicals, and related DME supply items assigned an Outpatient Prospective Payment System (OPPS) status indicator of “A” or “N” on CMS Addendum B or a status indicator of “N1” or “K2” on CMS Addendum BB. These changes will apply when services are reported by a physician or health care professional on a CMS-1500 claim with the following facility POS:

 POS 21 – Inpatient Hospital  POS 22 – Outpatient Hospital  POS 23 – Emergency Room  POS 24 – Ambulatory Surgical Center

Addendum B is used by CMS for the PPS for services rendered in a POS 21, 22, and 23. For more information, visit: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html.

Doc#: UHC2647d_20140214 Addendum BB is used by CMS for ASC services in a POS 24. For more information, go to: http://www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/ASCPayment/11_Addenda_Updates.html.

Please note that individual state regulations and contract requirements supersede specific policy language.

Note Regarding Reimbursement Policies

Unless otherwise noted below, these reimbursement policies apply to services reported using the CMS-1500 or its electronic equivalent, or its successor form.

UnitedHealthcare Community Plan reimbursement policies do not address all issues related to reimbursement for services rendered to our members, such as the member’s benefit plan documents, our medical policies, and the UnitedHealthcare Community Plan Physician, Health Care Professional, Facility and Ancillary Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Likewise, retirement of a reimbursement policy affects only those system edits associated with the specific policy being retired. Retirement of a reimbursement policy is not a guarantee of payment. Other applicable reimbursement and medical policies and claims edits will continue to apply.

Once implemented, the policies may be viewed at UHCCommunityPlan.com > For Health Care Professionals (click on the appropriate state) > Reimbursement Policy.

In the event of an inconsistency or conflict between the information in this Provider Notification and the posted policy, the provisions of the posted reimbursement policy prevail. If you have any questions, please contact your Health Plan Representative or call the number on your Provider Remittance Advice/Explanation of Benefits.

Doc#: UHC2647d_20140214