United Healthcare

United Healthcare Managed Care Committee Member

Shelby Jensen, CHONC - Newland Medical Associates

Medical Policy Updates for UnitedHealthcare Commercial & Affiliates UHC Individual Exchange/UHC Community Plan

Antiemetics for Oncology Updated Policy effective 8/1/23: “J1456 Injection, fosaprepitant (teva), not therapeutically equivalent to J1453” was added to the list.
Gonadotropin Releasing Hormone Analogs Updated Policy effective 8/1/23: “J1954 Injection, leuprolide acetate for depot suspension (cipla)” was added to the list.

Reimbursement Policy Updates for UnitedHealthcare Medicare Advantage

Discarded Drugs and Biologicals Policy, Professional
Effective October 1, 2023

Effective with date of service October 1, 2023, UnitedHealthcare Medicare Advantage will align with the Centers for Medicare and Medicaid (CMS) requirement for reporting of modifier JZ.
In accordance with CMS Medicare Claims Processing Manual Chapter 17 (Section 40) providers and suppliers are required to report the JZ modifier on all claims that bill for drugs from single-dose containers that are separately payable under Medicare Part B when there are no discarded amounts.

New Patient Visit Policy, Professional
Effective August 1, 2023

Per CMS guidelines, a “new patient” is a patient who has not received any professional services, i.e., Evaluation and Management (E/M) services or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years by the same individual or group physician.
Currently Medicare Advantage New Patient Visit Policy, Professional applies denials to new patient visits when a patient has received an E/M service within the previous 3 years by the same individual or group physician.
Effective with date of process 08/23/2023, UnitedHealthcare will expand the policy to better align with CMS to include other face-to-face services (e.g., surgical procedure) from the physician or physician group practice (same physician specialty) within the previous 3 years by the same individual or group physician.

Durable Medical Equipment, Orthotics and Prosthetics Policy, Professional
Effective October 1, 2023

The Durable Medical Equipment, Orthotics and Prosthetics Policy, Professional will be enhanced effective for dates of service on or after October 1, 2023.
To align with CMS Transmittal R12013CP, UnitedHealthcare will expand this policy to require that Healthcare Common Procedure Coding System (HCPCS) codes J1811, J1813 or J1817 for insulin furnished through an item of durable medical equipment be appended with modifier JK or JL to indicate a 30- or 90-day supply of insulin to allow for the appropriate coinsurance.