Health Plan News

TMA reimbursement specialists know how difficult it is to keep up with health plans’ constant changes. We are here to help you stay informed about the latest news from the major payers: Medicare, Medicaid, Aetna, Blue Cross and Blue Shield of Texas, Cigna, Humana, and UnitedHealthcare. Check back frequently for billing, coding, and health plan policy updates.

GeneralAetna | BCBS | Cigna | HumanaMedicare | Medicare Advantage | MedicaidUnited Healthcare

General

  • Pediatric, Booster COVID Vaccine Codes Established

    Now that federal health authorities have approved pediatric doses of the Pfizer COVID-19 vaccine, administrators of the vaccine should take note of these newly established CPT codes:

    Vaccine product code

    91307– Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use

    Vaccine administration codes

    0071A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; first dose 

    0072A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation; second dose

    In addition, a new code has been assigned to the Janssen booster for the COVID-19 vaccine:

    0034A – Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, DNA, spike protein, adenovirus type 26 (Ad26) vector, preservative free, 5x1010 viral particles/0.5 mL dosage; booster dose

    CPT copyright American Medical Association. All rights reserved.   

Aetna

  • Aetna Launching Patient-Facing Physician Performance Designation

  • Aetna Phasing Out Paper Checks
    If you don’t already receive direct deposits for claims payments from Aetna, enroll now to avoid receiving future Aetna payments by credit card.

    Now and throughout 2022, Aetna will phase out paper checks and explanations of benefits (EOBs). Sign up for direct deposit payments and electronic remittance advice using the new Aetna portal, Payer Enrollment Services. If you don’t enroll in direct deposits, you may receive future payments by virtual credit card, Aetna says.

    Receive EOBs via the Availity Remittance Viewer on the Aetna provider portal on Availity. You can print them out or save them to your computer. 

    Go to AetnaPaperlessOffice for more information.
  • Aetna Imaging Study Coding Tip
    Aetna requires an exact Current Procedure Terminology (CPT) code match between submitted claims and eviCore Healthcare’s authorizations for computerized tomography (CT) and magnetic resonance (MR) studies. Aetna will deny claims billed with nonmatching codes.
    Effective as of Jan. 1, 2021, this applies to Aetna commercial plan patients for whom Aetna requires preauthorization of certain radiation services. In addition to the specific type of imaging study, eviCore Healthcare, the authorization vendor, will make medical necessity determinations about the correct use of contrast for MR and CT procedures – and also will offer recommendations “for requests that are not appropriate based on the contrast component of the imaging procedure,” Aetna says. Note that the specific Healthcare Common Procedural Coding System codes for these contrast agents are not included in the eviCore Healthcare prior authorizations. You can find more information about coverage of specific contrast material in Aetna clinical policy bulletins.
    CPT copyright American Medical Association. All rights reserved.                    
  • Note These Member ID Card Changes for Medicare Advantage Plans
    Beginning Jan. 1, 2022, Aetna says you’ll see these changes on all Aetna MA plan ID cards:

    • “Group #” will be known as “Plan #.” For services performed on or after Jan. 1, 2022, use the plan number the same way you’ve used the group number in your transactions.

    Additional tips from Aetna:

    • If your Aetna patient doesn’t have current member ID card when checking in for an appointment, you can verify eligibility using the patient’s full first and last name and date of birth.
    • You can print an electronic copy of a patient’s ID card, if needed. Make sure eligibility details match the patient’s information. 

    Use the Aetna provider portal on Availity or other web vendor to check your patients’ eligibility and benefits. While it’s best to verify all patient eligibility before every visit, it’s an especially good idea to do so at the beginning of the year for patients with Medicare Advantage (MA) plans, as patients may have changed plans.

  • ER Surgical Procedures and Modifier 54
    Effective March 1, 2021, Aetna will pay for surgical procedures at 75% of the contracted surgery rate when performed by an emergency physician in the emergency department, whether or not the procedure is billed with modifier 54 (surgical care only). See details about modifier 54, a “split-care” modifier.
  • New Aetna Third-Party Claim Edit Coming
    Aetna will introduce new claim edits on March 1, 2021, as part of its third-party claim review. Aetna may ask you for medical records for certain claims, such as high-dollar claims, claims for implants, and bundled services claims. To access a prospective claims editing disclosure tool and find out if the new edits will apply to your claim, log in to the Availity provider portal. Then, then go to Aetna Payer Space > Applications > Code Edit Lookup Tools.

Blue Cross Blue Shield 

  • New Laboratory Program Coming Jan. 1
    Effective Jan. 1, 2022, Blue Cross and Blue Shield of Texas (BCBSTX) will implement new policies, and a new laboratory management program through Avalon Healthcare Solutions, for claims for certain outpatient laboratory services you provide to patients fully insured in BCBSTX commercial plans. You’ll have to access an Avalon online tool to use the program.

    • You can view both current and pending medical policies and clinical payment and coding policies on the BCBSTX provider website.

    • The new lab management program includes a post-service and prepayment review of outpatient lab claims with dates of service on or after Jan. 1, 2022. Typical outpatient settings are office, hospital outpatient, or independent lab; emergency department, hospital observation, and hospital inpatient settings are excluded from this program, BCBSTX says.

    Get access to Avalon’s Trial Claim Advice Tool via Availity. After logging to Availity, find the tool by using the single sign-on feature via the BCBSTX-branded Payer Spaces section within the Availity portal.

    You will use the tool to input laboratory procedure and diagnosis codes before submitting a claim, to see the potential outcome of your claim. Note, however, that this does not guarantee approval, coverage, or payment of services, according to BCBSTX. “Responses consider information entered through the tool for the date of service entered and historical claims finalized through the previous business day. Claims not yet finalized won’t be considered,” BCBSTX said.

    BCBSTX is offering free webinars about the Trial Claim Advice Tool and laboratory management program through Jan. 5, 2022.

  • BCBSTX Network Expands for Central Texas Plan
    Blue Cross and Blue Shield of Texas (BCBSTX) will expand its MyBlue Health network, effective Jan. 1, 2022, to Bexar, Travis, and Williamson counties.

    MyBlue Health members must choose a primary care physician. Some MyBlue Health members in these counties may choose a MyBlue Health Select PCP within the CentroMed, CommUnityCare, or Lone Star Circle of Care practice groups, which may result in a lower copayment for scheduled PCP office visits.

    The MyBlue Health plan name is displayed on covered patients’ BCBSTX ID card. In addition, MyBlue Health members have a unique network ID – BFT – and the three-character prefix is on the ID card is T2G. 

    If you have questions, contact your BCBSTX network management representative: 

  • State Employee HMO Patients to Move to HealthSelect
    Effective Sept. 1, 2021, Blue Cross and Blue Shield of Texas (BCBSTX) HMO plans will no longer be an enrollment option under the Texas Employees Group Benefits Program. All current patients enrolled in one of the HMO plans will be automatically enrolled in HealthSelect of Texas administered by BCBSTX, unless they elect otherwise during their summer enrollment period. HealthSelect participants must select a network primary care provider and notify BCBSTX of their selection within 60 days to get in-network benefits. Participants who transition from an HMO plan will have a 90-day referral grace period during which they will receive in-network benefits if they see an in-network specialist without a referral. Physicians can find more information about HealthSelect on the BCBSTX ERS Tools page. Patient information about the transition is on the Employees Retirement System of Texas website.

  • Texas Blues Reverses Policy to Discontinue Incident-To Billing, Averting Pay Cut

  • Erroneous Network Status Letters Mailed to Some Patients
    If your Blue Cross and Blue Shield of Texas (BCBSTX) patient has received a letter in error saying you will no longer be in network, you may request a retraction letter(s) by contacting your local BCBSTX network management consultant. In its March Blue Review, BCBSTX says the letters were result of a technical system error it aims to fix in second quarter 2021.

  • Note Network Participation in Blue Essentials Access, Blue Premier Access Plans
    Blue Cross and Blue Shield of Texas reminds physicians who sign a Blue Essentials or Blue Premier agreement that they are also in network for Blue Essentials Access or Blue Premier Access. The first two plans require patients to select a primary care physician (PCP) and obtain referrals to specialists. The latter two are HMO plans that do not require a PCP or referrals. 

  • Why Use CPT Category II Codes?
    CPT Category II codes are optional, supplemental tracking codes useful for performance measurement and tracking. Using these codes “will decrease the need for record abstraction and chart review [for performance measurement], and thereby minimize administrative burdens on physicians,” the American Medical Association says. The codes can also help you track screenings for your patients. The list of CPT II codes is updated annually according to Healthcare Effectiveness Data and Information Set (HEDIS) specifications published by the National Committee for Quality Assurance. Blue Cross and Blue Shield of Texas provides examples of HEDIS 2021 measures and applicable CPT II codes.

    CPT copyright American Medical Association. All rights reserved.             
  • Use POS 2 With Telehealth Claims
    Starting May 1, 2021, Blue Cross and Blue Shield of Texas may reject claims for professional telehealth services billed without place of service (POS) 02, and you’ll have to resubmit the claims with the correct POS to get paid. Claims billed with a telehealth procedure code or another CPT or HCPCS procedure code with telehealth modifiers (G0, GT, GQ, or 95) need to be billed with POS 02. 

    CPT copyright American Medical Association. All rights reserved.           
  • Bill Correctly for COVID-19 Vaccine, Administration
    As COVID-19 vaccines roll out across the country, the federal government is paying for the vaccine, and with a few exceptions, Blue Cross and Blue Shield of Texas (BCBSTX), or self-funded groups, will cover administration of the vaccine with no cost share for BCBSTX members. 

    The Centers for Medicare & Medicaid Services and the American Medical Association have assigned codes for each vaccine and its administration to use in submitting claims.

    Follow this instruction for BCBSTX claims: When billing a vaccine administration code with an office visit, if the vaccine is not the primary purpose of the office visit, bill the vaccine on a separate claim.  

  • Change Healthcare Collecting Record for Blue Cross
    Through May 2021, the Blue Cross and Blue Shield of Texas (BCBSTX) vendor Change Healthcare may contact you regarding records requests to collect data for the Healthcare Effectiveness Data and Information Set of the National Committee for Quality Assurance and the U.S. Department of Health and Human Services’ Quality Rating System. BCBSTX encourages you to respond within three to five days. 

  • Primary Care Physicians Can Earn a $100 Blue Cross Incentive 
    If you have Blue Cross Medicare Advantage PPO or HMO patients for whom you haven’t completed an annual health assessment since June 30 of last year, Blue Cross and Blue Shield of Texas (BCBSTX) will pay you an incentive to do so. For every eligible annual assessment you have completed or will complete for these patients from July 1, 2020, through the end of the COVID-19 public health emergency, you’ll receive an incentive payment of $100 in addition to your contracted rate. Submit your claim by March 31 for 2020 assessments. For 2021 assessments, BCBSTX will track your claims and make a lump payment in 2022. Learn more about the incentive and see coding guidelines, and for access to Indices, a reporting platform whereby you can view patients who haven’t had this annual wellness visit, email BCBSTX.

  • New List Helps ID When to Verify Coverage
    Blue Cross and Blue Shield of Texas (BCBSTX) has created a predetermination code list of procedures for which predetermination of benefits may be available and is recommended. Predetermination is a voluntary request for written verification of benefits before providing a service that may be considered experimental, investigational, or unproven, as specified in BCBSTX Medical Policy. Visit the BCBSTX’s Predetermination of Benefits Request page to view the list, find instructions for submitting a request electronically, or download a request form. 

  • BCBSTX Will Recoup Overpayment of Multiple Surgical Procedures
    Blue Cross and Blue Shield of Texas (BCBSTX) will begin post-payment reviews of claims on June 1, 2021, to make sure they adhere to its payment policy for multiple surgical procedures. According to BCBSTX, “you may have been paid 100%” for multiple procedures erroneously. For claims with dates of service of June 1 or later, BCBSTX will recoup any overpayments it finds against future claims.

    Under the multiple surgical procedure policy, when the same physician or physician group performs multiple procedures on the same patient in the same operative session, only the primary procedure will pay 100% of the allowed amount. Secondary or subsequent procedures will pay at 50%.

    • The surgical procedure with the highest allowed amount is primary. If two procedures have the same allowed amount, only one will be considered primary.
    • For bilateral procedures, if the surgical procedure for either side is the highest allowed amount, one procedure will pay at 100% and the second one, as well as all other secondary procedures, at pay will at 50%. If at least one other surgical procedure is the highest allowed amount, the bilateral procedure (both sides combined) will be paid at 75% and all other secondary procedures at 50%.

    Some procedures may be exempt from this policy and pay 100% of the allowed amount (see the policy for details). Also, Medicare, Medicare supplement, and BCBSTX as secondary payer policies are exempt.
  • Blue Cross May Have Assigned Primary Care Physicians in Error
    On Jan. 1, 2021, Blue Cross and Blue Shield of Texas (BCBSTX) became aware of a system error that may result in an erroneous primary care physician number assignment to Blue Cross Medicare Advantage HMO members, according to the payer.
    If you receive an error message when accessing Availity, continue to treat the assigned members and, if applicable, refer them to in-network providers. If you receive any inappropriate claim denials, BCBSTX says it will automatically reprocess them after the system is corrected. Call BCBSTX at (800) 676-2583 with any questions.
  • BCBSTX May Terminate Unused Provider Record IDs
    Blue Cross and Blue Shield of Texas may automatically cancel a provider record ID that has no claim dates of service within a 12-month period. This also will result in termination of associated networks. Provider record IDs are specific to billing/rendering National Provider Identifiers and tax identification numbers.

Cigna

  • Cigna Policy Changes 
    Cigna announced these policy changes in its fourth-quarter newsletter:

    • Effective for claims processed on or after Oct. 27, 2021, Cigna will deny payment for CPT codes billed with modifier 26 for the professional component of a service when: 
      • The Medicare Physician Fee Schedule doesn’t recognize the existence of a professional component for a particular code; or
      • The facility is contractually responsible for lab management and oversight services. 
       
    • Effective Nov. 14, 2021, Cigna will change how it processes claims for emergency room evaluation and management (E&M) services billed with CPT codes 99284 and 99285. Find more information in the Reimbursement Policies section (log-in required) of Cigna’s Policy Updates October 2021 page.
    • Beginning Jan. 1, 2022, the following gastroenterology procedures will require precertification for patients covered by a Cigna commercial plan: 
      • Esophagoscopy/Esophagogastroduodenoscopy (EGD); and
      • Most capsule endoscopies.  

    Submit precertification requests to Cigna via eviCore.com

    • Effective for claims processed on or after Nov. 14, 2021, Cigna will administratively deny E&M services as not separately payable when billed with the removal of impacted cerumen when the removal is the sole reason for the visit. This affects E&M CPT codes 99202-99205 billed with 69209 or 69210 for cerumen removal. 
    • Reminder: Percertification for some procedures requires a medical necessity review of the site of care. For example, see Site of Care: Outpatient Hospital for Select Musculoskeletal Procedures. A 15-minute training about Cigna musculoskeletal site-of-care precertification, including a new attestation process, is available from EviCore. See also EviCore’s Cigna Implementation Resources for musculoskeletal services. 
    CPT copyright American Medical Association. All rights reserved.  
  • Cigna Medicare Advantage Expand Reach and Services
    Cigna reports it is expanding its Medicare Advantage plans into more markets. Patients covered by Cigna plans will have some new benefits in 2022. 

    • $0 copay for annual physical with their primary care physician;
    • Insulin savings program;
    • Part D low-income subsidy;
    • Expanded telehealth services;
    • Cash rebates for prescription medicine copays;
    • Monthly food allowance for eligible patients; and
    • Pairing of companions for older adults.
     
  • Tips for Successful Referrals
    Cigna recommends that primary care physician have a clearly defined referral process to help make sure patients keep their appointments with specialists, specialists receive the information they need, and there is follow-up. Cigna offers these tips for successful referrals of patients to specialty care.
    1. Make sure your patients understand why you are referring them to a specialist and that they agree to it. Let them know if they need to schedule the appointment themselves or if the specialist office will contact them and provide them the specialist’s contact information and office location. 
    2. In your communication with the specialist, clearly state the clinical questions you are asking that physician, and provide supporting data and specifics related to the urgency of the referral. Also clarify what you are asking the specialist to do, such as make an evaluation, perform a specific procedure, or assume care until the patient is stable.
    3. Keep track of open referrals; if you don’t hear from the specialist, call to get a report. Either way, acknowledge the specialist’s recommendations. Then, make notes in the patient’s chart about the referral and outcomes as a result of the specialist’s evaluation or other actions.
    For resources and additional tips regarding referrals, see Cigna’s Network News, Fourth Quarter 2021 (page 9).
  • Cigna May Deny Venipuncture Code
    Effective Oct. 16, 2021, Cigna will deny CPT code 36415 (routine venipuncture; the puncture of a vein with a needle or an IV catheter to withdraw blood) when billed with certain lab codes as incidental. “The method of obtaining the sample is integral to performing the laboratory analysis when reported by the same provider,” Cigna says.

Humana

  • Humana Newsletter Has a New Name 
    In case you missed it. … Humana’s quarterly e-newsletter is now Humana Physicians News (formerly Humana’s YourPractice). You can subscribe to the newsletter, or access it on the Humana website.

    Between newsletters, keep an eye on the Availity Portal to stay abreast of important notifications about changes to Humana policies.

Medicare

  • Watch for Your Comparative Billing Report
    In late November 2021, the Centers for Medicare & Medicaid Services (CMS) will issue comparative billing reports (CBRs) on Part B claims for critical care evaluation and management services. Use the data-driven tables to compare your billing and payment patterns with peers in Texas and across the nation.

    CBRs aren’t publicly available. Look for an email from cbrpepper.noreply@religroupinc.com to access your report. Update your email address in the Provider Enrollment, Chain, and Ownership System to ensure delivery.

    For more information, visit the CBR website. You also can view a webinar recording on CBR, or register for a live webinar to be held Dec. 1, 2-3 pm CT. 

  • “Amount in Controversy” for Medicare Appeals to Hold Steady for 2022
    For Medicare appeals filed in calendar year 2022, the minimum “amount in controversy” (AIC) required for an administrative law judge hearing or review of a dismissal is $180, the same as for 2021, Novitas Solutions reports. In addition, the 2022 AIC for federal district court will remain the same as in 2021, at $1,760.

    The amount in controversy is calculated thus:

    Amount charged minus Medicare payments already made or awarded = subtotal balance

    Subtotal balance minus any applicable deductible/coinsurance = AIC 

  • Connect Before Nov. 1 to New Novitas EDI Gateway
    Novitas Solutions, the Medicare payer for Texas, has introduced a new electronic data exchange (EDI) gateway for electronic billing of Medicare claims. The new gateway is available now, and you must connect to it before Nov. 1, 2021. The existing gateway will be retired on that date.

    Start your connection by following this readiness checklist from Novitas. For details about the actions summarized on the checklist, visit the Novitas website.

    There are no changes to how you connect to Novitasphere, the Novitas portal, although transition details regarding claim submission through Novitasphere will come soon, Novitas says. If you have questions, contact a Novitas EDI analyst at (855) 252-8782, Option 3. 
  • Fact Sheet Summarizes Medicare Payment for E&M Visits
    Medicare has generally adopted the new American Medical Association coding, language, and interpretive guidance framework for office and outpatient evaluation and management (E&M) visits (CPT codes 99201 through 99215), effective Jan.1, 2021. See this fact sheet for more information, including:

    • Payment of Medicare’s add-on codes for prolonged office and outpatient visits (G2212) and visit complexity (G2211), and
    • Medical review when time is used to select visit level. 
    CPT copyright American Medical Association. All rights reserved.                          
  • Medicare Updates Codes Accepted With Cost-Sharing Modifier
    The Centers for Medicare & Medicaid Services has updated the list of codes (ZIP) physicians can use with the cost-sharing (CS) modifier to identify a service as subject to the cost-sharing waiver for COVID-19 testing-related services. For dates of service on or after Jan. 1, 2021, through the end of the public health emergency, Medicare will accept these codes with the CS modifier:

    • HCPCS codes G2250, G2251, and G2252, and
    • CPT codes 98970, 98971, and 98972 (these replace HCPCS codes G2061-G2063, which are accepted for services provided in 2020).   
    • CPT codes 98966, 98967, and 98968 are accepted for services with the CS modifier provided on or after March 18, 2020. 
    CPT copyright American Medical Association. All rights reserved.                              
  • Novitasphere Login to Change Jan. 15
    The log-in screen for Novitasphere, the physician portal for Medicare payer Novitas Solutions, will change slightly on Jan. 15 when the Centers for Medicare & Medicaid Services (CMS) adopts a new identity management system for CMS applications. Your existing Novitas user ID and password will migrate to the new system. When you log in, you’ll be prompted to select your multifactor authentication (MFA) device and enter the code. If you no longer have access to the email address associated to your user ID, you need to update the address before midnight on Jan. 14, on the CMS Enterprise portal. Note that the Novitasphere helpdesk will no longer provide a one-time MFA passcode after the transition; you must rely on your MFA device to receive it. Remember, you must log into www.novitasphere.com every month to keep your access active.

Medicare Advantage

  • Collect Medicare Info to Bill for Medicare Advantage COVID-19 Vaccine Administration
    Physicians contracted with Medicare Advantage plans should submit to original Medicare – not to the plan carriers – claims for administering a COVID-19 vaccine to their Medicare Advantage patients. To submit the claim to Medicare through Novitas Solutions, the Medicare payer for Texas, your practice will need to have on file your Medicare Advantage patient’s original Medicare card or Medicare ID number. Be sure to have your staff collect this when Medicare Advantage patients make appointments to receive a COVID-19 vaccine.

    Bill only for the vaccine administration when you’ve received the COVID-19 vaccine doses from the  government for free; don’t include the vaccine codes on the claim. Any other services you provide the patient on the same date should be filed to the Medicare Advantage plan. 

Medicaid

  • Beware of Services Not Payable With a Medicaid Child Checkup
    A Texas Medicaid policy may trip up physicians who perform child checkups under Texas Health Steps, the program that covers children aged 0 through 20 who are eligible for Medicaid.

    The policy says: “Components of a medical checkup that have an available CPT code are not reimbursed separately on the same day as a medical checkup,” with some exceptions (Section 5.3.6 THSteps Medical Checkup in the Texas Medicaid Provider Procedures Manual, Volume 2).

    For example, the Texas Health and Human Services Office of Inspector General recently sent a refund request on the basis of this policy to a physician who billed a Medicaid payer for audiometry (CPT 92551) with a child well-check.

    Exceptions under the policy are initial point-of-care blood lead testing, mental health screening for adolescents, postpartum depression screening, tuberculin skin test, developmental and autism screening, vaccine administration, and oral evaluation and flouride varnish. 

    CPT copyright American Medical Association. All rights reserved.      

United Healthcare

  • Stay Connected With UnitedHeathcare Tools
    Some upgrades and other changes coming over the next few months will change how you interact with UnitedHeathcare (UHC) digital tools. Be aware of these dates in spring and summer 2021:

    As of March 3, referral information will no longer be available on the Link dashboard. Instead, you’ll access it using the UnitedHealthcare Provider Portal, as UHC continues to retire tools from Link and upgrade its digital services to the new system. You can use your current Link login credentials to access the UnitedHealthcare Provider Portal. Read more information.

    In May, the patient management tool UHCCareConnect will transition to a new application, Practice Assist. You won’t need to do anything differently, UHC says; you’ll still access it through the Link portal. UHC says Practice Assist will provide better access to population data, personal data, and more.

    Update your web browser by Aug. 17, as Microsoft will no longer support Internet Explorer 11 online services. To get the best user experience with UHC’s online tools and help stay protected against security threats, UHC recommends changing your default web browser to Microsoft Edge, Google Chrome, or Apple Safari. Here’s how.

  • UHC to Update Lab Services Policy 
    UnitedHealthcare (UHC) will revise its Lab Services Policy, Professional, for commercial plans effective June 1, 2021. UHC says highlights of the change are these:

    • Lab panel bundling criteria will require all individual component lab codes to be present, as set forth in Current Procedural Terminology.
    • The lab panel code should be reported only if all components of the lab panel are rendered.
    • Consistent with guidelines in Centers for Medicare & Medicaid Services Local Coverage Determinations, the policy will deny certain multiplex PCR respiratory viral panels of six or more pathogens.
    CPT copyright American Medical Association. All rights reserved.                    
  • Find UnitedHealthcare Patients’ Medicare IDs
    Need your UnitedHealthcare (UHC) Medicare patient’s original Medicare ID number so you can bill Novitas Solutions for COVID-10 vaccine administration? (See above: Collect Medicare Info to Bill for Medicare Advantage COIVID-10 Vaccine Administration.) UHC has added Medicare IDs under Eligibility & Benefits on the UnitedHealthcare Provider Portal.
  • CIOX Health May Ask You for UnitedHealthcare Medical Records 
    A chart retrieval vendor for UnitedHealthcare, CIOX Health, may contact you in February 2021 for patient information as part of the Centers for Medicare & Medicaid Services (CMS) Risk Adjustment Data Validation Audit for benefit year 2019 (which had been paused due to COVID-19). CMS performs this audit of patients it selects randomly to validate the accuracy of codes submitted by plans for payment. If your patient has been selected, CIOX Health will request medical records to support the auditor. You can find a video tutorial to learn about electronic submission of medical records at cioxlink.com.
  • UnitedHealthcare to Require Preferred Lab Network Integration 
    Staring April 1, 2021, for commercial UnitedHealthcare (UHC) plans, physicians with an electronic health record (EHR) will be required to allow at least one Preferred Lab Network (PLN) provider integration into the EHR. If you don’t have a Preferred Lab Network integrated into your EHR for lab testing, go to UHC’s Preferred Lab Network webpage and complete this integration request form to identify the PLN you’d like to use for integration.
  • Submit Social Determinants of Health Codes to UnitedHealthcare 
    A UnitedHealthcare (UHC) protocol encourages physicians to routinely screen all your UHC patients for social determinants of health (SDoH), document SDoHs in the patients’ medical record using these ICD-10 diagnostic code(s), and submit the codes to UHC. This code list may be updated, so keep an eye on it. 

Last Updated On

November 16, 2021

Originally Published On

December 18, 2020