Private Payer Roundup, August 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. 


Revised payment policy: Effective for dates of service on or after July 3, 2016, UnitedHealthcare (UHC) revised its Pediatric and Neonatal Critical and Intensive Care Services Policy for its commercial plans. 

While the American Medical Association Current Procedural Terminology code book gives specific direction for the appropriate reporting of pediatric and neonatal critical and intensive care services and time-based critical care codes, the revised UHC policy allows separate payment for evaluation and management (E&M) codes 99221-99233, 99468-99480, and 99291 when provided in addition to pediatric and neonatal critical care (codes 99468-99476 and 99477-99480) by a physician of a different specialty in the same group practice on the same date of service for the same patient.  

UHC notes that separate payment for these E&M services may be subject to editing in other payment policies such as the Same Day/Same Service and Rebundling policies. You can review these policies on the UHC website. 

New policy calls for CLIA identification: Effective Nov. 1, 2016, for physicians participating in its commercial and Medicare Advantage plans (and Aug. 1, 2016, for nonparticipating physicians), UHC will implement a new payment policy applicable to all laboratory services. The policy requires that all claims for laboratory services include the Clinical Laboratory Improvement Amendments (CLIA) number for the servicing physician. The physician’s physical address also will be required if it differs from the billing physician’s address noted on the claim. The billing or servicing address must match the address associated with the CLIA ID number. 

New Link applications to launch: Starting in September, UHC will introduce new applications on its gateway site, Link

  • eligibilityLink will have features from the current Eligibility & Benefits application plus additional ones, like the ability to view previous plans from the past 18 months.
  • claimsLink will combine the features of the Claims Management and Claims Reconsideration applications and add more, like the ability to create a new claim reconsideration request.

UHC says these new applications will not launch to all users at the same time; when they are available to you, UHC will email you with more details and information about webinar training sessions. Concurrently, UHC will start retiring the Eligibility & Benefits, Claim Status, and Claim Reconsideration functions on Pop-up boxes will prompt you to try out and switch to the new applications. The existing applications will be available into 2017.

Note also: Prior authorization and notification is now available as a separate Prior Authorization and Notification application. These functions will continue to be available as part of the Eligibility & Benefits application as well.

Source: UnitedHealthcare Network Bulletin, August 2016


Precertification updates: Effective Sept. 1, 2016, Aetna will no longer require precertification for: 

  • Elective nonemergent transportation by ambulance or medical van, and 
  • Repair of entropion and ectropion.

Blepharoplasty, canthopexy and canthoplasty procedures will still require precertification.

Effective Jan. 1, 2017:

  • Aetna participating physicians will need precertification only when requesting services at a nonparticipating dialysis facility. 
  • Aetna will still require precertification for cochlear device and ventricular assist device (VAD) services. However: 

    • Replacement items for use with the cochlear implant won’t require precertification. This includes replacement headset/headpieces, microphones, coils, cables, external speech processors, and external controller components. Quantity limits may still apply. For more information, see Clinical Policy Bulletin (CPB) #0013 — Cochlear Implants and Auditory Brainstem Implants. 
    • Miscellaneous VAD replacement supplies and accessories won’t require precertification. For more information, see CPB #0654 — Ventricular Assist Devices. 
  • Ophthalmic medical injectables will require precertification. This includes Eylea (aflibercept), Macugen (pegaptanib), and Lucentis (ranibizumab).
  • The following drugs/medical injectables won’t require precertification: Aloxi IV (palonosetron HCl), Anzemet IV (dolasetron mesylate), Jevtana (cabazitaxel), Aredia (pamidronate), Boniva (ibandronate), Reclast (zoledronic acid), and Zometa (zoledronic acid).

Help patients stay in network: Do you participate in the Aetna Premier Care Network? It’s a network for businesses with employees in locations across the country. In certain geographic areas, those employees have a limited provider network for specific types of care. Because many of your existing patients soon will be participating in open enrollment and selecting a new medical plan, it helps them if you know your network participation status. This will help them make sure they stay in network for their care so they pay less. Starting in October, you can check Aetna’s provider online referral directory to see if you’re participating in the Aetna Premier Care Network. You’ll also see changes for 2017. If you have questions, call Aetna at (888) 632-3862, or send in your question online.

Reminder: Separate ID card for patients with contraceptive benefits: Some of your Aetna patients may be enrolled in the payer’s Contraceptive Services Payment Program; these enrollees must present a separate ID card for contraceptive services. The program is for patients of reproductive age (and their covered female dependents) who are covered by the qualifying group health plan or student health insurance coverage. Look for “Contraceptive Services Payment Program” on the top front of the card.

Source: Aetna OfficeLink Updates, September 2016

Published Aug. 26, 2016


Last Updated On

August 26, 2016

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