Private Payer Roundup, July 2016

In case you missed these — here is a roundup of useful items from health care payment plans’ newsletters and updates, compiled by TMA’s reimbursement specialists.

If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA Hassle Factor Log to help resolve insurance-related problems. Visit for more resources and information. 

New From TMA: Network Adequacy Complaint Form for Patients  

Patients have several options when filing a complaint with the Texas Department of Insurance (TDI) about their health plan’s network.  

TMA has created a draft complaint form letter MembersOnlyRed that practices can customize as their own. You can give the letter to your patients at the time of service. Complaints about a health plan’s network may include problems locating a specialist who is accepting new patients, finding a doctor within reasonable driving distance from the patient’s home, or inaccurate information in the health plan’s provider directory. 

You may want to file a complaint at the same time as the patient, either independently or included as supporting documentation with the patient’s complaint. Supporting documentation is vital when filing a complaint.


Payment policy changes name, scope: As of July 1, 2016, the name of UnitedHealthcare’s (UHC’s) Inpatient Consultation Policy has been changed to the Consultation Services Policy to reflect the policy’s expanded scope. The policy aligns with the American Medical Association Current Procedural Terminology guidelines and requires claims submitted with dates of service on or after July 1, 2016, to include the referring entity’s name and/or National Provider Identifier (NPI) for consultation codes 99241-99245, 99251-99255, G0406-G0408, and G0425-G0427. Report this information in fields 17 or 17b on the CMS 1500 claim form or its electronic equivalent.

TMA’s reimbursement specialists advise following the above procedure regardless of payer.

Source: UnitedHealthcare

Tier 1 and Premium designation changes: Beginning in January 2017, you’ll see changes in how UHC uses its Tier 1 indicator and displays physicians’ Premium designations. 

Tier 1 changes — “Tier 1” indicates a Tier 1 provider in the patient’s benefit plan. 

  • Tier 1 provider status will be used exclusively for tiered benefit plans and NexusACO products. Only patients in health plans that offer tiered plans will see the Tier 1 indicator. 
  • Tier 1 will be expanded to include high-value accountable care organization physicians and care providers, UnitedHealth Premium Care physicians, and/or other select physicians and care providers specific to each patient’s benefit plan. 
  • Patients in health plans that offer tiered benefits may pay less for services provided by Tier 1 physicians and providers. 

Until January 2017, members in UHC commercial health plans that offer tiered benefits may continue to pay lower copays and coinsurance amounts for services provided by UnitedHealth Premium Tier 1 physicians. These physicians have received the Premium designation for: 

  • Quality and Cost Efficiency, or 
  • Cost Efficiency and Not Enough Data to Assess Quality.

UnitedHealth Premium designation icon updates — The Premium designation program will use the new icons to indicate the designations of physicians in the provider directory:  


Schedule timely postpartum care: UHC reminds you that the American College of Obstetricians and Gynecologists recommends physicians conduct a routine postpartum visit to assess the baby’s health and mom’s mood, a contraceptive plan, return to sexual activity, and breastfeeding. UHC measures postpartum visit compliance using the Healthcare Effectiveness Data and Information Set standard of a postpartum visit on or between 21 and 56 days after delivery.

 Along with the date of the visit, include one of the following in the medical record: 

  • Pelvic exam — evaluation of weight, blood pressure, breasts and abdomen (notation of “breastfeeding” is acceptable for “evaluation of breasts”);
  • Notation of postpartum care such as “PP care” or “PP check;” or
  • Preprinted Postpartum Care Form in which information was documented during visit. 

UHC offers these tips for improving compliance with postpartum visits: 

  • Stress the importance of postpartum care during prenatal visits. 
  • Schedule the postpartum visit prior to discharge from the hospital. 
  • Provide an appointment reminder by phone or postcard. 
  • Ensure proper documentation in medical record.
  • Use correct diagnosis and procedure codes.

Source: UnitedHealthcare Network Bulletin, July 2016

Published July 28, 2016

Last Updated On

April 20, 2018

Originally Published On

July 28, 2016

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