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Your Questions Answered
Learn about the exemption which allows you to accept a referral from
a physician not licensed in New York; Find out if Medicare covers PT and OT
ervices for one patient provided at the same time? Discover the answers in this issue.
What’s new

UHC is Retiring Fax Numbers Used for Medical Prior Authorization Requests
In order for UHC to improve the ease at which their services can be used, they have implemented online Prior Authorization and Notification tools. These tools will serve to replace the majority of the old and outdated Fax based systems. The new method will be available through the Link website, which is the same website as is used for eligibility and claims checking.
Updated Requirements for Specialty Medical Injectable Drugs for UnitedHealthcare Commercial, Medicare Advantage and Community Plan Members
UnitedHealthcare members benefit from access to the highest quality and most affordable medications. New requirements have been implemented for commercial, Medicare Advantage, and Community Plan members.
Site of Service Reviews for Certain Musculoskeletal Surgical Procedures (Arthroscopic and Foot Surgery) — Revised Effective Date for Certain States
Prior authorization must be requested for musculoskeletal surgical procedures, in compliance with the Notification and Prior Authorization Requirements Protocol. Effective as of August 2, 2019, this prior authorization will schedule a review of the site of service, in order to ensure that health care services are of high quality.
Prior Authorization Change for Referrals and Services at Out-of-State and Out-of-Network Care Providers.
Changes to the way in which prior authorization is granted entered into force on July 1, 2019. The new ruling is applicable for new referrals and UnitedHealthcare members and for out of state hospitals, to name a few.
CPT Code Changes and Modifications to Approved Prior Authorizations
For UnitedHealthcare commercial plans, enhancements and improvements to the prior authorization process will be implemented immediately, as per feedback from existing commercial plans members. The changes will enable providers to make changes and updates to CPT codes, as part of an existing prior authorization request.
Advanced Practice Provider Evaluation And Management Procedures Policy
For the Oxford Commercial Plans, new reimbursement rules and regulations will be applied effective as of August 1, 2019, to ensure physicians reporting (E/M) services on behalf of their employed Advanced Practice Healthcare Providers are reporting the services correctly.
Consultation Services Policy
Effective as of October 1, 2019, Oxford Commercial Plan policy changes for Consultation Services.
Laboratory and Pathology Protocol Penalty Update
The New York & Connecticut Participating Provider Laboratory and Pathology Protocol requires the use of participating laboratory and pathology providers, unless the member agrees, in writing, in advance, on Oxford’s Consent Form to use a nonparticipating lab or pathologist.
Multiple Radiology Payment Reduction
Changes are being implemented for the reimbursement of diagnostic imaging procedures, effective as of October 1, 2019. These changes will reduce payment of professional component for subsequent diagnostic imaging services, while the highest valued procedure will be reimbursed 100% of the fee schedule or contracted/negotiated rate.
Fidelis Care authorization grids have been updated effective July 1, 2019.
Changes and updates are being made to a number of sections of the Fidelis Care Authorization Grids, effective as of July 1, 2019. These changes will largely be regarding the Behavioral Health – Outpatient Services.
Precertification/Prior Authorization Requests Submission Process to Change
Prior authorization requests and precertification rules will soon be changed and updated in order to make amendments to the ways in which requests are accepted. The main change will regard the use of Fax software for the transmission of these requests to Horizon NJ Health, and the new use of the Care Affiliate software for the submission of the aforementioned requests.
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2019