May Network Bulletin 2019

Transcript

1 MAY 2019 net work bulletin An important message from UnitedHealthcare to health care professionals and facilities. Enter UnitedHealthcare respects the expertise of the physicians, health care professionals and their staff who participate in our network. Our goal is to support you and your patients in making the most informed decisions regarding the choice of quality and cost-effective care, and to support practice staff with a simple and predictable administrative experience. The Network Bulletin was developed to share important updates regarding UnitedHealthcare procedure and policy changes, as well as other useful administrative and clinical information. Where information in this bulletin conflicts with applicable state and/or federal law, UnitedHealthcare follows such applicable federal and/or state law.

2 May 2019 UnitedHealthcare Network Bulletin Table of Contents Front & Center PAGE 3 Stay up to date with the latest news and information. UnitedHealthcare Commercial PAGE 13 Learn about program revisions and requirement updates. UnitedHealthcare PAGE 23 Reimbursement Policies Learn about policy changes and updates. UnitedHealthcare Community Plan PAGE 25 Learn about Medicaid coverage changes and updates. UnitedHealthcare Medicare Advantage PAGE 35 Learn about Medicare policy, reimbursement and guideline changes. Doing Business Better PAGE 40 Learn about how we make improved health care decisions. UnitedHealthcare Affiliates PAGE 44 Learn about updates with our company partners. State News PAGE 52 Stay up to date with the latest state/regional news. 877-842-3210 or visit UHCprovider.com . 2 | For more information, call

3 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Stay up to date with the latest news and information. Smart Edits Announces Congratulations to Our Go Updates to Requirements Informational Release Edits Paperless Sweepstakes for Specialty Medical ad of Time to Alert You Ahe Winners! Enter Today for Injectable Drugs for Your Chance to Win $500 UnitedHealthcare Commercial You told us it would be helpful and Community Plan to learn about upcoming policy Could you be next? Go Paperless changes that may affect the now for your chance to win. We’re making some updates claims you submit. In response, to our requirements for certain UnitedHealthcare is implementing specialty medications for many of Informational Smart Edits messages. Out-of-Network Lab our UnitedHealthcare commercial, These messages provide you with Approval Required UnitedHealthcare Community Plan the opportunity to find out about and UnitedHealthcare Medicare Aug. 1, 2019 new policies being implemented in Advantage members. These Your UnitedHealthcare Participation the future. requirements are important to provide Agreement requires that when our members access to care that’s you refer members to other care medically appropriate as we work providers, you’ll refer them to UnitedHealthcare Preferred toward the Triple Aim of improving UnitedHealthcare in-network care Lab Network Launches health care services, health outcomes, providers, unless an exception July 1, 2019 and overall cost of care. applies. If an exception applies, We are excited to announce the labs beginning Aug. 1, 2019, you’ll selected to be part of the Preferred need to follow our online process Fax Numbers Used for Lab Network effective July 1, 2019. to demonstrate that to us prior UnitedHealthcare West The Preferred Lab Network consists to referring members with Medical Prior Authorization of currently contracted independent, UnitedHealthcare commercial benefit free-standing laboratory care Requests Will Retire plans to out-of-network laboratories providers that have met higher for testing services. Aug. 5, 2019 standards for access, cost, data, As we continue moving administrative quality and service, based on a tasks online, another group of fax rigorous application and review numbers used for UnitedHealthcare process. The Preferred Lab Network West medical prior authorization providers will be highlighted in our requests will retire on Aug. 5, 2019. directories starting July 1, 2019, to make it easy for members and care providers to identify them. 877-842-3210 UHCprovider.com . 3 | For more information, call or visit

4 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Stay up to date with the latest news and information. 2019 UnitedHealthcare Therapeutic Continuous Glucose Monitors Coverage Administrative Guide: for UnitedHealthcare Update to the Claims Medicare Advantage Plans Disputes and Appeals Information in the UnitedHealthcare Medicare Capitated and/or Delegated Advantage Plans allow coverage of therapeutic Continuous Glucose Supplement Monitors (CGMs) and associated We added a section called supplies (i.e., sensors, receiver Contracted Care Provider Reminder on Special Needs and transmitter) under the Part B Disputes. This update is on the Durable Medical Equipment (DME) Plan Model of Care Training HTML version of the guide on benefit when Centers for Medicare The Centers for Medicare & UHCprovider.com/guides and on & Medicaid Services criteria are met. Medicaid Services (CMS) requires page 120 of the PDF. Care providers who want to obtain Special Needs Plans (SNPs) to coverage of a therapeutic CGM for provide initial and annual Model of their patients should contact one Care (MOC) training to all network Codes Added to New Prior of the two following network DME providers contracted to see SNP Authorization Category providers: Byram Healthcare for members and all out-of-network Effective July 1, 2019, a new prior Dexcom and Libre or Edgepark for providers seen by SNP members authorization category — Stimulators Dexcom and Libre. routinely. UnitedHealthcare offers the — will be implemented for SNP MOC training as a pre-recorded UnitedHealthcare Community Plan. session that takes about 10 minutes As of result of this new category, Global Shortage of Bacillus to complete. Please complete the existing prior authorization required -Guérin (BCG) for Calmette annual training module. codes will be re-categorized. Bladder Cancer UnitedHealthcare has received Pharmacy Update: Notice questions about how to bill Inventory Control Number of Changes to Prior when using one vial of Bacillus (ICN) Is Being Updated to Calmette -Guérin (BCG) for multiple Authorization Requirements Include Alpha Characters patients. Claims are unable to be and Coverage Criteria In May of 2019, we’ll begin to include processed for decimal amounts or for UnitedHealthcare alpha characters in our existing units <1. When billing for BCG, enter Commercial and Oxford Inventory Control Numbers (ICNs). “1” as the unit of drug supplied even A pharmacy bulletin outlining Instead of receiving numeric ONLY when administering a partial vial to upcoming new or revised clinical ICNs or claims numbers, you will a patient. However, when a partial programs and implementation begin to see the ICNs including alpha vial is administered to the patient, dates is now available for characters and numeric characters. only bill UnitedHealthcare for the UnitedHealthcare commercial plans cost of the actual amount of drug at UHCprovider.com/pharmacy. administered to the member. 4 | For more information, call or visit UHCprovider.com . 877-842-3210

5 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Smart Edits Announces Informational Release Edits to Alert You Ahead of Time You spoke, we listened. You told us it would be helpful to learn about upcoming policy changes that may affect the claims you submit. In response, UnitedHealthcare is implementing Informational Smart Edits messages. These messages provide you with the opportunity to find out about new policies being implemented in the future. CSP — Consultation Code (Informational Alert Only) Speeding Up Claims, Together • UnitedHealthcare is revising the Consultation Services UnitedHealthcare has been using an EDI edit solution Policy and will no longer reimburse CPT® codes called Smart Edits, which identifies claims with potential 99241-99255. This change aligns UnitedHealthcare errors before they are processed. Reviewing the Smart with the Centers for Medicare & Medicaid Services 277CA clearinghouse Edits messages that appear on the (CMS). We would like to partner with care providers and resubmitting with the suggested revisions report on older fee schedules (2009 and prior) to move to will reduce claim error rates, denials and resubmissions more current fee schedules. and help improve claims processing time. Care providers who submit professional claims electronically to Payer ID You can find out more information about this policy in the 87726 should receive Smart Edits. March Network Bulletin . umAT/umONP — Always Therapy (Informational Stay In the Know Alert Only) Since the November 2018 Network Bulletin • Effective with dates of service on or after July 1, announcement, several smart edit releases have 2019, the GN, GO or GP modifiers will be required on been deployed for UnitedHealthcare Medicare “Always Therapy” codes to align with CMS. Advantage, UnitedHealthcare Community Plan and • According to CMS, certain codes are “Always UnitedHealthcare commercial plans. You can stay up Therapy” services, regardless of who performs them, to date on all active edits and resources by visiting and always require a therapy modifier (GP, GO or GN) . s UHCprovider.com/smartedit to indicate they’re provided under a physical therapy, Care providers with an active Link profile can visit the occupational therapy or speech-language pathology Smart Edits training page for a refresher on UHC On-air plan of care. Smart Edits and also in-depth, edit-specific training at You can find out more information about this policy in the UHCprovider.com . April Network Bulletin . For more information about the Smart Edit logic, contact the EDI Support Team at or call [email protected] . 800-842-1109 UHCprovider.com or visit 877-842-3210 5 | For more information, call .

6 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center UnitedHealthcare Preferred Lab Network Launches July 1, 2019 We are excited to announce the following labs were selected to be part of the Preferred Lab Network effective July 1, 2019: • AmeriPath Inc. The Preferred Lab Network consists of currently contracted independent, free-standing laboratory care providers that • BioReference Laboratories, Inc. have met higher standards for access, cost, data, quality and • GeneDX service, based on a rigorous application and review process. We’ll work with these distinguished labs to continue our • Invitae Corporation efforts to improve the care provider and member experience. • LabCorp The Preferred Lab Network providers will be highlighted • Mayo Clinic Laboratories in our directories starting July 1, 2019, to make it easy for members and care providers to identify them. • Quest Diagnostics Inc. For more information on how UnitedHealthcare’s Triple Aim focus — improving health care affordability, outcomes and the patient experience — is now adding more value for lab services, visit newsroom.uhc.com/experience/ preferred-lab-network.html . You can also visit Preferred Lab Network on UHCprovider.com > Menu > Reports and . Quality Programs Congratulations to Our Go Paperless Sweepstakes Winners! Enter Today for Your Chance to Win $500 The most recent Go Paperless Sweepstakes winner was Candella LLC in Iowa. now for your chance to win. Go Paperless Could you be next? 6 | For more information, call or visit . UHCprovider.com 877-842-3210

7 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Out-of-Network Lab Approval Required Aug. 1, 2019 Out-of-network laboratory referrals can create excess costs in the health care system and may pose a potential quality risk to your patients. To help protect your patients, you are required to refer lab services to a participating lab provider. The following requirement applies only to UnitedHealthcare commercial plans. For an exception to this requirement, you must have both: UnitedHealthcare maintains a large network of regional and local labs. These labs provide a fast, comprehensive • Written consent from the member to use an range of services. They also provide clinical data and -of -network laboratory for that member’s lab out related information to support: service for that date of service. The consent indicates • Healthcare Effectiveness Data and Information Set the member has discussed the option to use an in-network lab with their care provider and they have (HEDIS®) reporting made an informed decision to receive services from an • Care management -of -network laboratory despite the potential increased out • UnitedHealth Premium® program -of -pocket costs associated with that decision. out • Other clinical quality improvement activities • UnitedHealthcare approval to refer the member to use an out-of-network laboratory for that member’s lab To find in-network laboratories, please visit service for that date of service. > Search for a Provider > UHCprovider.com/findprovider Medical Directory > choose the member’s health plan and Beginning Aug. 1, 2019, UnitedHealthcare will state > Places > Labs and Imaging > Lab Locations. require an online process to satisfy the exception requirements outlined above, prior to referring If you can’t find an in-network laboratory for a specific lab members with UnitedHealthcare commercial benefit test, call us at the Provider Services number listed on the plans to out-of-network laboratories for testing member’s ID card before ordering the test. We’ll work with you services. This requirement does not apply to in-network to find a laboratory where covered tests can be performed. laboratory referrals or when the referring provider has We’ll post additional directions on submission obtained a network exception to refer the member to a UHCprovider.com of the online approval on non-participating laboratory. prior to Aug. 1, 2019. If you have any questions, Your UnitedHealthcare Participation Agreement requires contact your network account manager or that when you refer members to other care providers, provider advocate. you’ll refer them to UnitedHealthcare in-network care providers, unless an exception applies. If an exception applies, beginning Aug. 1, 2019, you’ll need to follow our online process to demonstrate that to us prior to referring members with UnitedHealthcare commercial benefit plans to out-of-network laboratories for testing services. 7 | For more information, call 877-842-3210 or visit . UHCprovider.com

8 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Updates to Requirements for Specialty Medical Injectable Drugs for UnitedHealthcare Commercial and Community Plan We’re making some updates to our requirements for certain specialty medications for many of our UnitedHealthcare commercial and Community Plan members. These requirements are important to provide our members access to care that’s medically appropriate as we work toward the Triple Aim of improving health care services, health outcomes and overall cost of care. These requirements will apply whether members are new to therapy or have already been receiving these medications. • On July 1, 2019, for UnitedHealthcare commercial What’s Changing for UnitedHealthcare plans (including affiliated plans for Oxford, UMR Community Plan and Neighborhood Health Partnership) use of these Spravato™ has been added to the Review at Launch medications for all diagnoses will require prior for UnitedHealthcare Community Plan. This list Drug List authorization with this policy change. UHCprovider.com/en/policies- protocols/ is located at • On Aug. 1, 2019, for UnitedHealthcare affiliate comm-planmedicaid-policies/medicaid-community- plans UnitedHealthcare of the Mid-Atlantic and state-policies.html Review at Launch for New through the UnitedHealthcare of the River Valley, use of these to Market Medications drug policy. medications for all diagnoses will require prior authorization. What’s Changing for UnitedHealthcare Commercial and Community Plan Members For both UnitedHealthcare commercial and Community Plan members, current authorizations will be honored through Clinical Policy and Prior Authorization Updates their end date. Upon authorization renewal, the updated Effective July 1, 2019, our White Blood Cell Colony policy will apply. Care providers are encouraged to begin Stimulating Factors medical drug policy will be updated using the preferred Colony Stimulating Factor products. to include preferred product coverage criteria. Preferred If you administer any of these medications without first product language will be added as follows: completing the notification/prior authorization process, the • Use of Neulasta® Onpro® and Neulasta® vial prior to claim may be denied. Members can’t be billed for services the use of Fulphila™ and Udenyca™ denied due to failure to complete the notification/prior In addition to the preferred product changes to the authorization process. drug policy, UnitedHealthcare commercial plans will be expanding the current prior authorization requirements on these medications to include use for any diagnosis: • Neulasta Onpro/Neulasta, Fulphila, and Udenyca currently require prior authorization when used to treat a cancer diagnosis. . UHCprovider.com or visit 877-842-3210 8 | For more information, call

9 UnitedHealthcare Network Bulletin Table of Contents May 2019 Front & Center Fax Numbers Used for UnitedHealthcare West Medical Prior Authorization Requests Will Retire Aug. 5, 2019 Some plans have a state requirement for fax capability Use Our Online Tools and will continue to have a fax option for their members. As we continue moving administrative tasks online, However, you can still use the Prior Authorization and UnitedHealthcare the following fax numbers used for Notification tool on Link to submit requests for those West medical prior authorization requests will retire on members. Aug. 5, 2019: Go to UHCprovider.com/fax for a list of all Retiring Fax Numbers retired fax numbers and information about fax numbers used for inpatient admission 800-978-7457 800-274-0569 800-497-3264 notifications. 866-718-6105 800-526-5863 800-283-7523 800-944-7690 866-718-6107 800-438-5470 888-714-3991 877-331-5855 866-743-9735 Instead of faxing your request, please use the Prior Authorization and Notification Tool on Link. You can access the tool and view resources and training to help you get started at UHCprovider.com/paan . If you’re unable to use the Prior Authorization and Notification tool on Link, call Provider Services at the number on the back of the member’s ID card to submit a request by phone. 2019 UnitedHealthcare Administrative Guide: Update to the Claims Disputes and Appeals Information in the Capitated and/or Delegated Supplement We added a section called Contracted Care Provider Disputes. This update is on the HTML version of the guide on and on page 120 of the PDF. UHCprovider.com/guides . 877-842-3210 or visit UHCprovider.com 9 | For more information, call

10 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Codes Added to New Prior Authorization Category Beginning July 1, 2019, a new prior authorization category — Stimulators — will be implemented. As of result of this new category, existing prior authorization required codes will be re-categorized. This change doesn’t impact any requirements or criteria. Some stimulator codes may still remain under existing categories. The new category applies to UnitedHealthcare Community Plan (all plans) : Codes New Category Current Category 0312T, 0313T, 0314T, 0315T, 0316T, 0317T, 43647, 43648, Stimulators Bariatric Surgery 43881, 43882, 64590 Bone growth stimulators Stimulators E0747, E0748, E0749, E0760 Experimental and 61863, 61864, 61867, 61868, 61885, 61886, 64555 Investigational Service 61863, 61864, 61867, 61868, 61885, 61886, 64555 Stimulators Potentially Unproven Service 63650, 63655, 63685, 64553, 64555, L8680, L8682 Spinal Cord Stimulators Stimulators 64570, 63650, 63655, 63685, 64553, 64555, 64570 Stimulators Spinal Surgeries 61885, 64568, L8680, L8685, L8686, L8687, L8688 Vagus nerve stimulation Stimulators Inventory Control Number (ICN) Is Being Updated to Include Alpha Characters This May, we’ll begin to include alpha characters in our existing Inventory Control Numbers. Instead of receiving numeric ONLY ICN’s or claims numbers, you will begin to see the ICNs including alpha characters and numeric characters. The length of the ICN will remain the same. There are no changes to the existing submission processes. • Existing ICNs: 2345678912 • Enhanced ICNs: AB23456789 10 | For more information, call or visit UHCprovider.com . 877-842-3210

11 UnitedHealthcare Network Bulletin May 2019 Table of Contents Front & Center Reminder on Special Needs Plan Model of Care Training The Centers for Medicare & Medicaid Services (CMS) requires Special Needs Plans (SNPs) to provide initial and annual Model of Care (MOC) training to all network providers contracted to see SNP members and all out-of-network providers seen by SNP members routinely. UnitedHealthcare offers the SNP MOC training as a pre-recorded session that takes about 10 minutes to complete. Please complete the annual training module. SNPs are responsible for conducting their own MOC • If you do not have an Optum ID, you may register for UHCprovider.com one at training, which means you may be asked to complete . Click on New User and multiple trainings by different health plans. follow the directions listed there. Please allow 24–48 hours for your new Optum ID to give you access. If The training includes information about the different types of you experience a problem with registration, please SNPs tailored to individual needs. You’re considered a SNP contact your security administrator. care provider if you see UnitedHealthcare plan members who have benefits under a Medicare Advantage SNP. • Once registered with your Optum ID, go to UHCprovider.com > Menu > Resource Library > Please complete this year’s training by Oct. 1, 2019: Training > 2019 Special Needs Plan Model of Care , enter your HERE • To complete the training, click Training Special Needs > UHC on Air . Optum ID and watch the program. For questions, please email us at [email protected] or call 888-878-5499 . Pharmacy Update: Notice of Changes to Prior Authorization Requirements and Coverage Criteria for UnitedHealthcare Commercial and Oxford A pharmacy bulletin outlining upcoming new or revised clinical programs and implementation dates is now available online for UnitedHealthcare commercial plans. Go to . UHCprovider.com/pharmacy UHCprovider.com 11 | For more information, call 877-842-3210 or visit .

12 UnitedHealthcare Network Bulletin Table of Contents May 2019 Front & Center Therapeutic Continuous Glucose Monitors Coverage for UnitedHealthcare Medicare Advantage Plans UnitedHealthcare Plans allow Medicare Advantage Care providers who want to obtain coverage of a coverage of therapeutic Continuous Glucose Monitors therapeutic CGM for their patients should contact one of the two following network DME providers: (CGMs) and associated supplies (i.e., sensors, receiver for Dexcom 877-902-9726 Byram Healthcare at and transmitter) under the Part B Durable Medical and Libre or Edgepark at 800-321-0591 Equipment (DME) benefit when Centers for Medicare & for Dexcom and Libre. Medicaid Services criteria are met. Therapeutic CGMs are not eligible for coverage under the patient’s pharmacy benefit and are not available at the pharmacy. -Guérin (BCG) for Bladder Cancer Global Shortage of Bacillus Calmette -Guérin (BCG) Live, use of low-dose intravesical BCG may Because of limited supplies of Bacillus Calmette provide an option for treatment of more patients with bladder cancer without compromising efficacy and with less toxicity.* UnitedHealthcare has received questions about how to bill when using one vial of BCG for multiple patients. Claims are unable to be processed for decimal amounts or units <1. When billing for BCG, enter “1” as the unit of drug supplied even when administering a partial vial to a patient. However, when a partial vial is administered to the patient, only bill UnitedHealthcare for the cost of the actual amount of drug administered to the member . * Zeng et al. Low-Dose Versus Standard Dose of Bacillus Calmette-Guerin in the Treatment of Nonmuscle Invasive Bladder Cancer A Systematic Review and Meta-Analysis. Medicine 2015; 94: 1-10. UHCprovider.com 12 | For more information, call 877-842-3210 or visit .

13 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial Learn about program revisions and requirement updates. UnitedHealth Premium® July 1, 2019 Prescription Drug List Updates Program Preview Mailer Sent in May The July 1, 2019 Prescription Drug List and pharmacy benefit In early May 2019, the UnitedHealth updates for UnitedHealthcare Premium program will begin sending commercial plans are now available a preview mailer to administrators of at UHCprovider.com > Menu > Premium eligible groups. The mailer Resource Library > Drug Lists and includes information on updates to Pharmacy. the Premium program, including new claims data collection dates and additions to the quality measures Participating Provider and cost efficiency methodology. Risk Adjustment Data Laboratory and Pathology Validation (RADV) Audit Protocol Program Coverage Update Pharmacy: UnitedHealthcare and for Biktarvy®, Genvoya® In compliance with the Risk UnitedHealthcare Oxford require Adjustment Data Validation (RADV) and Stribild® physicians and other qualified health audit program under the Affordable care professionals to inform patients UnitedHealthcare commercial Care Act (ACA), we’re required when referring them to or including plans that have implemented the by the Department of Health and an out-of-network care provider in My ScriptRewards pilot program Human Services (HHS) to provide the patient’s health plan. To help have new coverage guidelines for supporting medical documentation that disclosure process and save select HIV medications. Effective for the annual medical claims members potential costs from using March 1, 2019, members newly review audit for UnitedHealthcare an out-of-network care provider, prescribed Biktarvy®, Genvoya® commercial members. We’ll be beginning June 1, 2019, network or Stribild® need to take action to requesting medical records within a care providers in Connecticut continue receiving coverage for their specific 2018 service date(s) starting and Maryland must obtain medication. in June 2019. Since only a number consent from UnitedHealthcare or of members will be randomly UnitedHealthcare Oxford members selected, not all care providers will before referring them to or using receive this request. out-of-network laboratories and pathologists for their care. 877-842-3210 . UHCprovider.com 13 | For more information, call or visit

14 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial Learn about program revisions and requirement updates. UnitedHealthcare Outpatient UnitedHealthcare Medical Policy, Medical Benefit Injectable Cancer Therapy Drug Policy and Coverage Prior Authorization Determination Guideline Requirement Updates Beginning Aug. 1, 2019, prior authorization for outpatient injectable chemotherapy and related cancer therapies listed below will be required for UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance Company of the River Valley, UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, Optimum Choice, Inc., and MD Individual Practice Association, Inc. Optum, an affiliate company of UnitedHealthcare, will manage these prior authorization requests. . UHCprovider.com or visit 877-842-3210 14 | For more information, call

15 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Commercial Risk Adjustment Data Validation (RADV) Audit Program In compliance with the Risk Adjustment Data Validation (RADV) audit program under the Affordable Care Act (ACA), we’re required by the Department of Health and Human Services (HHS) to provide supporting medical documentation for the annual medical claims review audit for UnitedHealthcare commercial members. We’ll be requesting medical records within a specific 2018 service date(s) starting in June 2019. Since only a number of members will be randomly selected, not all care providers will receive this request. What’s being requested from you? If your claim is in the sample, you’ll be contacted to submit the medical records as outlined below. Please include only the minimum Health Insurance Portability and Accountability Act (HIPAA) necessary documentation: • Demographics sheet • Medication list • Operative/Procedure notes • Progress Notes/Face-to-face office visits • Prescription for laboratory services • Consultation reports/notes • Problem list • Discharge summary • Radiology and pathology services • Emergency room records • Radiology reports • History and physical exam UnitedHealthcare will use CIOX Health to conduct the request for medical records. CIOX Health can be reached . CIOX has a new fast, easy and secure way to electronically submit medical records. See at 877-445-9293 for a short video tutorial. cioxlink.com UnitedHealth Premium® Program Preview Mailer Sent in May In early May 2019, the UnitedHealth Premium program will begin sending a preview mailer to administrators of Premium eligible groups. The mailer includes information on updates to the Premium program, including new claims data collection dates and additions to the quality measures and cost efficiency methodology. The mailer will also be available online in early May at UnitedHealthPremium.UHC.com > Help and Support > . Premium Training For more information about the Premium program, including the Version 12 methodology, go to Contact Premium . 866-270-5588 UnitedHealthPremium.UHC.com > Help and Support > or call 877-842-3210 . UHCprovider.com or visit 15 | For more information, call

16 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Commercial Pharmacy: Coverage Update for Biktarvy®, Genvoya® and Stribild® UnitedHealthcare commercial plans that have implemented the My ScriptRewards pilot program have new coverage guidelines for select HIV medications. Effective March 1, 2019, members newly prescribed Biktarvy®, Genvoya® or Stribild® need to take action to continue receiving coverage for their medication. They will now have three grace fills and action must be taken before the 4th fill to continue to receive coverage of their medication. Patients and their prescribers will receive a letter after the member’s first fill, informing both parties of the options available. The grace fill program only applies to members in plans that participate in My ScriptRewards. One of the following actions must be taken: My ScriptRewards My ScriptRewards is designed to help improve access to 1. Members can talk to their care provider about lower- cost options and, if one is right for them, their care clinically appropriate and affordable treatment regimens provider can write a new prescription. for UnitedHealthcare commercial plan members with -cost HIV infection. The program provides select lower 2. The member and/or their care provider can choose combination antiretroviral therapies available at $0 to continue therapy with the initial prescribed -of -pocket with up to $500 in additional benefits. out 877-636-9712 medication, contact OptumRx® at and Members who fill $0 cost-share medications and enroll advise the patient care coordinator that they don’t on myscriptrewards.com are eligible to receive two want to change to a lower-cost option. $250 pre-paid debit cards a year to use towards their medical expenses (e.g., lab fees, office copays and other How You Can Help Your Patients Save Money prescriptions). You can help your patients reduce their out-of-pocket For more information, costs by reviewing Prescription Drug List (PDL) information . myscriptrewards.com visit for tiers and copay ranges, which vary by plan. For example, the following chart shows the HIV medications covered under the My ScriptRewards program in Tier 1 at $0 copay and Tier 2 and Tier 3 options on the PDL with mid-range to highest copays. Tiers and Copay ranges for members Medications Cimduo™, Isentress®/Isentress HD* and Tivicay®* Tier 1: Zero to $ — Lowest copay Tier 2: $$ — Mid-range copay Juluca®, Symfi®, Symfi Lo® and Triumeq® Tier 3: $$$ — Highest copay Biktarvy, Genvoya and Stribild . UHCprovider.com or visit 877-842-3210 16 | For more information, call

17 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Commercial Participating Provider Laboratory and Pathology Protocol , UnitedHealthcare and UnitedHealthcare As announced in the March Network Bulletin Oxford require physicians and other qualified health care professionals to inform patients when referring them to or including an out-of-network care provider in the patient’s health plan. To help that disclosure process and save members potential costs from using an out-of-network care provider, beginning June 1, 2019, network care providers in Connecticut and Maryland must obtain consent from UnitedHealthcare or UnitedHealthcare Oxford members before referring them to or using out-of-network laboratories and pathologists for their care. If the member does not have out-of-network – Affected Services benefits, then the member will be responsible • Specimens collected in the office and sent to an -network under their plan for the costs of the out-of out -of-network laboratory or pathologist for processing laboratory/pathology services. • Providing a member with a prescription, requisition or • If you do not send us a signed copy of the form other form to obtain laboratory or pathology services showing the member has consented to the use outside your office of an out-of-network laboratory or pathologist within 15 days of our request), then we’ll reverse Points to Remember the claim for the Evaluation & Management (E&M) • For each episode of care, you’ll need to submit a service from the office visit that generated the separate Laboratory and Pathology Services Consent out-of-network laboratory or pathology service, Form, unless the occurrence is part of an ongoing and administratively deny the claim for non- monitoring procedure. compliance with this protocol. If we’ve made any previous payments for the E&M service, that • Each form is only valid for 15 days from the date of amount will be subject to recovery (and you may signature, unless the “Ongoing Monitoring” box is not bill the member for such amount). selected, in which case the form is valid for one year from the date of signature. • If you collect specimens in your office and use a network laboratory or pathologist for processing, this • If the member indicates on the consent form that protocol will not apply. they choose to use an out-of-network laboratory or pathologist and: • Use of network laboratories and pathologists is always required, with the exceptions of services authorized by If the member has out-of-network benefits, then – us or a payer, or those provided in emergency situations. the out-of-network laboratory/pathology claim will be processed according to the member’s -network benefits under the member’s plan -of out and any out-of-network cost shares will apply. CONTINUED > . UHCprovider.com or visit 877-842-3210 17 | For more information, call

18 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial < CONTINUED Participating Provider Laboratory and Pathology Protocol Resources For Maryland Only For more details about the Participating Provider The Participating Provider Laboratory and Pathology Protocol does not apply to claims for services arising Laboratory and Pathology Protocol, visit: under plans underwritten by MAMSI Life and Health > Policies and Protocols > Protocols UHCprovider.com • Insurance Company, MD-Individual Practice Association, oxhp.com > Providers > Tools & Resources > Medical • Inc. or Optimum Choice, Inc. Please refer to the and Administrative Policies > Policy Update Bulletin Administrative Guide, for more information for these plans. (You can find the full Participating Provider Laboratory and Pathology Protocol, Participating Provider Laboratory and Pathology FAQs and Laboratory and Pathology Services Consent Form for Members) If you have questions, call Provider Services at 877-842-3210 . July 1, 2019 Prescription Drug List Updates The July 1, 2019 Prescription Drug List and pharmacy benefit updates for UnitedHealthcare commercial . Drug Lists and Pharmacy plans are now available at UHCprovider.com > Menu > Resource Library > 877-842-3210 . UHCprovider.com or visit 18 | For more information, call

19 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Commercial UnitedHealthcare Outpatient Injectable Cancer Therapy Prior Authorization Requirement Beginning Aug. 1, 2019, prior authorization for outpatient injectable chemotherapy and related cancer therapies listed below will be required for UnitedHealthcare Plan of the River Valley, Inc., UnitedHealthcare Insurance Company of the River Valley, UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, Optimum Choice, Inc., and MD Individual Practice Association, Inc. Optum, an affiliate company of UnitedHealthcare, will manage these prior authorization requests. Prior authorization will be required when adding a new To submit an online request for prior authorization, sign in injectable chemotherapy drug or cancer therapy to an to Link and access the Prior Authorization and Notification existing regimen. tool. Select the “Radiology, Cardiology + Oncology” box. After answering two short questions about the state you In addition, prior authorization will be required for work, you will be directed to another website to process therapeutic radiopharmaceuticals. these authorization requests. Prior authorization will be required for: Therapeutic Radiopharmaceuticals That Require Prior Authorization • Chemotherapy and biologic therapy injectable drugs (J9000 – J9999), Leucovorin (J0640) and Prior authorization is required for the following: Levoleucovorin (J0641) • Lutetium Lu 177 (Lutathera®) • Chemotherapy and biologic therapy injectable drugs • Radium RA-233 dichloride (Xofigo®) that have a Q code • All therapeutic radiopharmaceuticals that have not yet • Chemotherapy and biologic therapy injectable drugs received an assigned code and will be billed under that have not yet received an assigned code and will a miscellaneous Healthcare Common Procedure be billed under a miscellaneous Healthcare Common Coding System (HCPCS) Procedure Coding System (HCPCS) code • Colony Stimulating Factors: HCPCS Codes for Therapeutic Radiopharmaceuticals – Filgrastim (Neupogen®) J1442 Therapeutic radiopharmaceuticals billed under the – Filgrastim-aafi (Nivestym™) Q5110 following HCPCS codes require prior authorization: – Filgrastim-sndz (Zarxio®) Q5101 • A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi – Pegfilgrastim (Neulasta®) J2505 • A9606 Radium RA-223 dichloride, therapeutic, per – Pegfilgrastim-jmdb (Fulphila™) Q5108 microcurie – Sargramostim (Leukine®) J2820 • A9699 Radiopharmaceutical, therapeutic, not – Tbo-filgrastim (Granix®) J1447 otherwise classified • Denosumab (Brand names Xgeva® and Prolia®): J0897 CONTINUED > UHCprovider.com or visit 877-842-3210 19 | For more information, call .

20 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial < CONTINUED UnitedHealthcare Outpatient Injectable Cancer Therapy Prior Authorization Requirement If a member receives injectable chemotherapy drugs or related cancer therapies in an outpatient setting between May 1, 2019 and July 31, 2019, you don’t need to request prior authorization until you administer a new chemotherapy drug or related cancer therapy. We will authorize the chemotherapy regimen the member was receiving prior to Aug. 1, 2019. The authorization will be effective until March 31, 2020. or visit 20 | For more information, call . UHCprovider.com 877-842-3210

21 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates For complete details on the policy updates listed in the following table, please refer to the April 2019 Medical Policy Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Commercial Medical & Drug Policies and Coverage Determination Guidelines > Medical Policy Update Bulletins . Effective Date Policy Title Policy Type NEW Medical June 1, 2019 Preimplantation Genetic Testing UPDATED/REVISED Actemra® (Tocilizumab) Injection for Intravenous Infusion Drug April 1, 2019 Bone or Soft Tissue Healing and Fusion Enhancement Products Medical April 1, 2019 May 1, 2019 CDG Breast Reconstruction Post Mastectomy Breast Repair/Reconstruction Not Following Mastectomy CDG May 1, 2019 Medical June 1, 2019 Chromosome Microarray Testing (Non-Oncology Conditions) April 1, 2019 Clotting Factors, Coagulant Blood Products & Other Hemostatics Drug Cochlear Implants Medical April 1, 2019 April 1, 2019 Computerized Dynamic Posturography Medical Denosumab (Prolia® & Xgeva®) Drug April 1, 2019 Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical CDG April 1, 2019 Supplies and Repairs/Replacements Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Medical April 1, 2019 April 1, 2019 Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome Medical Medical April 7, 2019 Fecal Calprotectin Testing Gastrointestinal Motility Disorders, Diagnosis and Treatment Medical May 1, 2019 CONTINUED > 21 | For more information, call UHCprovider.com or visit . 877-842-3210

22 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Commercial < CONTINUED UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates Policy Title Policy Type Effective Date UPDATED/REVISED Infliximab (Remicade®, Inflectra™, Renflexis™) Drug April 1, 2019 Intrauterine Fetal Surgery Medical May 1, 2019 Ketamine April 1, 2019 Medical Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) April 1, 2019 URG Scan — Site of Care Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Medical April 1, 2019 Treatment Decisions Medical Occipital Neuralgia and Headache Treatment April 1, 2019 Drug Ocrevus™ (Ocrelizumab) April 1, 2019 Orencia® (Abatacept) Injection for Intravenous Infusion April 1, 2019 Drug Pectus Deformity Repair CDG April 1, 2019 Rituximab (Rituxan® & Truxima®) Drug April 1, 2019 Self-Administered Medications List Drug April 1, 2019 April 1, 2019 Drug Simponi Aria® (Golimumab) Injection for Intravenous Infusion Stelara® (Ustekinumab) April 1, 2019 Drug Thermography Medical April 1, 2019 Trogarzo™ (Ibalizumab-Uiyk) Drug April 1, 2019 Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. or visit 22 | For more information, call . UHCprovider.com 877-842-3210

23 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Reimbursement Policies Learn about policy changes and updates. Unless otherwise noted, the Coordinated Commercial UnitedHealthcare following reimbursement policies Reimbursement Policy Community Plan apply to services reported using Announcement Reimbursement Policy: the 1500 Health Insurance Claim UnitedHealthcare will implement Reimbursement policies that apply Form (CMS-1500) or its electronic to UnitedHealthcare Community several commercial reimbursement equivalent or its successor form. policy enhancements. Plan members are located here: UnitedHealthcare reimbursement Health UHCprovider.com > Menu > policies do not address all Plans by State > [Select State] factors that affect reimbursement > “View Offered Plan Information” for services rendered to under the Medicaid (Community UnitedHealthcare members, Plan) section > Bulletins and including legislative mandates, Newsletters. We encourage you member benefit coverage to regularly visit this site to view documents, UnitedHealthcare reimbursement policy updates. medical or drug policies, and the UnitedHealthcare Care Provider Administrative Guide. Meeting the terms of a particular reimbursement policy is not a guarantee of payment. Once implemented, the policies may be viewed in their entirety at UHCprovider.com > Menu > Policies and Protocols > Commercial Policies > Reimbursement Policies for . In the event Commercial Plans of an inconsistency between the information provided in the Network Bulletin and the posted policy, the posted policy prevails. UHCprovider.com 23 | For more information, call 877-842-3210 or visit .

24 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Reimbursement Policies Coordinated Commercial Reimbursement Policy Announcement The following chart contains an overview of the policy changes and their effective dates for the following policies: Procedure to Modifier Policy, Professional; Consultation Services Policy, Professional. Summary of Change Policy Effective Date Procedure to July 1, 2019 • Effective with dates of service on or after July 1, 2019, the GN, GO or GP Modifier Policy, modifiers will be required on “Always Therapy” codes to align with the Professional Centers for Medicare & Medicaid Services (CMS). • According to CMS, certain codes are “Always Therapy” services regardless of who performs them, and always require a therapy modifier (GP, GO or GN) to indicate they’re provided under a physical therapy, occupational therapy or speech-language pathology plan of care. “Always Therapy” modifiers are necessary to enable accurate reimbursement • for each distinct type of therapy in accordance with member group benefits. • As previously announced in the March and April 2019 Network Bulletins, July 1, 2019 Consultation UnitedHealthcare is revising the Consultation Services Policy and will no Services Policy, longer reimburse CPT® codes 99241-99255. Professional • Effective with dates of service of June 1, 2019, UnitedHealthcare will no longer reimburse CPT codes 99241-99255 when billed by any health care professional or medical practice with a participation agreement that includes contract rates determined on a stated year 2010 or later CMS RVU basis. • Effective with dates of service of Oct. 1, 2019, UnitedHealthcare will no longer reimburse CPT codes 99241-99255 when billed by any health care professional or medical practice. • When services are rendered at the request of another physician or appropriate source, care providers should submit an appropriate E/M service in alignment with either the 1995 or 1997 CMS coding guidelines. • With respect to telehealth and telemedicine services, the Telehealth & Telemedicine Policy will continue to apply and HCPCS codes G0406 – G0408, G0425 – G0427, G0508 and G0509 will be payable pursuant to that policy, the participation agreement and the member’s benefit plan. • A video presentation with more information can be viewed on UHC On Air. Additionally, a course for CEU/CME credits entitled “Evaluation and Management Coding: Back to Coding Basics” is also available through Link on UHCprovider.com . • We would like to continue partnering with care providers on older fee schedules (2009 and prior) to move to more current fee schedules. Care providers with questions about their fee schedule may reach out to their UnitedHealth Network representative. or visit . UHCprovider.com 24 | For more information, call 877-842-3210

25 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Community Plan Learn about Medicaid coverage changes and updates. Care Management Coordination of Care Prior Authorization Required for Therapeutic between Primary Care The UnitedHealthcare Community Plan Case Management program Physicians and Specialists Radiopharmaceuticals is a holistic approach to care for UnitedHealthcare wants to Effective Aug. 1, 2019, members with complex needs, UnitedHealthcare will require underscore the importance of especially for those with chronic prior authorization for therapeutic ongoing communication between conditions. The goal is to keep our radiopharmaceuticals administered primary care physicians (PCPs) members in the community with the on an outpatient basis for and specialists. PCPs and resources necessary to maintain the UnitedHealthcare Community Plan specialists share responsibility for highest functional status possible. communicating essential patient members in Mississippi information about consultations, and Tennessee. treatment plans and referrals. Clinical Guidelines Failure to consistently communicate Clinical Practice Guidelines are threatens the ability to provide Utilization Review available at UHCprovider.com > high-quality patient care. UnitedHealthcare Community Plan Menu > Health Plans by State > Select staff performs concurrent review on State > Medicaid (Community Plan) inpatient stays in acute, rehabilitation > Policies and Clinical Guidelines. Member Rights and and skilled nursing facilities, as Guidelines are available for diabetes, Responsibilities well as prior authorization reviews asthma, perinatal care, preventive of selected services. A listing of As a reminder, the UnitedHealthcare services, ADHD, depression and services requiring prior authorization Community Plan Member Rights many other conditions. is available in the Provider Manual. and Responsibilities can be found in the Provider Manual at UHCprovider. com/guides. Member Rights and Responsibilities are distributed to new members upon enrollment. 877-842-3210 . UHCprovider.com or visit 25 | For more information, call

26 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan Learn about Medicaid coverage changes and updates. Cultural Competence Site of Care Medical Necessity Reviews and We work to try to identify gaps in Revised Prior Authorization care related to a member’s language and cultural needs. To help reduce Requirements for Speech, those gaps and improve culturally Occupational, and Physical competent care, we’re reminding Therapy Services — care providers that UnitedHealthcare Effective May 13, 2019 Community Plan’s members have a UnitedHealthcare Community Plan right to receive care that is culturally of Florida aims to improve cost appropriate and respects their efficiencies for the overall health cultural and ethnic background and care system. One way we’ll do origins. Appointment Availability that is by conducting site of care Standards medical necessity reviews for all As a reminder, UnitedHealthcare speech, occupational and physical Pharmacy Updates Community Plan has appointment therapy services. We’re also revising As a reminder, pharmacy updates availability requirements for primary our existing prior authorization are available online at UHCprovider. care physicians and specialists. The requirements. For dates of service com > Menu > Health Plans by requirements apply to routine, urgent on or after May 13, 2019, once State > Select State > Medicaid and after-hours care. prior authorization for speech, (Community Plan) > Pharmacy occupational, or physical therapy Resources and Physician services is requested in accordance Administered Drugs. UnitedHealthcare with our prior authorization Community Plan Medical requirements, we’ll determine whether the site of care is medically Policy, Medical Benefit necessary, including cost effective, Drug Policy and Coverage consistent with Florida’s Agency for Determination Guideline Health Care Administration (AHCA) Updates definition of medical necessity. Site of care reviews will be conducted only if the service will be performed in an outpatient hospital. UHCprovider.com or visit 877-842-3210 26 | For more information, call .

27 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Community Plan Prior Authorization Required for Therapeutic Radiopharmaceuticals Effective Aug. 1, 2019, UnitedHealthcare will require prior authorization for therapeutic radiopharmaceuticals administered on an outpatient basis for UnitedHealthcare Community Plan members in Mississippi and Tennessee. To submit an online request for prior authorization, sign in HCPCS codes impacted by this prior authorization will to Link and access the Prior Authorization and Notification include: tool. Then select the “Radiology, Cardiology + Oncology” • A9513 Lutetium Lu 177, dotatate, therapeutic, 1 mCi box. After answering two short questions about the state • A9606 Radium RA-223 dichloride, therapeutic, per you work in, you’ll be directed to a website to process microcurie these authorization requests. • A9699 Radiopharmaceutical, therapeutic, not The following products will require authorization: otherwise classified • Lutetium Lu 177 (Lutathera) Prior authorization for therapeutic radiopharmaceuticals • Radium RA-233 dichloride (Xofigo) will not be required for UnitedHealthcare Community Plan • All therapeutic radiopharmaceuticals that have not yet members in Iowa. received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS). Utilization Review UnitedHealthcare Community Plan staff performs concurrent review on inpatient stays in acute, rehabilitation and skilled nursing facilities, as well as prior authorization reviews of selected services. A listing of services requiring prior authorization is available in the Provider Manual. A physician reviews all cases in which the care does not appear to meet guidelines. Decisions on coverage are based on the appropriateness of care and service and existence of coverage. We do not provide financial or other rewards to our physicians for issuing denials of coverage or for underutilizing services. during normal business hours, 877-542-9235 If you have questions or would like specific criteria, call Monday – Friday. 27 | For more information, call . UHCprovider.com or visit 877-842-3210

28 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan Coordination of Care between Primary Care Physicians and Specialists UnitedHealthcare wants to underscore the importance of ongoing communication between primary care physicians (PCPs) and specialists. PCPs and specialists share responsibility for communicating essential patient information about consultations, treatment plans and referrals. Failure to consistently communicate threatens the ability to provide high-quality patient care. Relevant information from the PCP should include the Information exchange among care providers should be timely, relevant and accurate to facilitate ongoing patient patient’s history, diagnostic tests and results, and the reason for the consultation. The specialist is responsible management. The partnership between the PCP and specialist is based on the consistent exchange of clinical for timely communication of the results of the consultation and on-going x and treatment plans. information, and this information is a critical factor in providing quality patient care. Member Rights and Responsibilities As a reminder, the UnitedHealthcare Community Plan Member Rights and Responsibilities can be found in the Provider Manual at . Member Rights and Responsibilities are distributed to UHCprovider.com/guides new members upon enrollment. On an annual basis members are referred to their handbook to review their Member Rights and Responsibilities. UHCprovider.com 28 | For more information, call 877-842-3210 or visit .

29 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Community Plan Care Management The UnitedHealthcare Community Plan Case Management program is a holistic approach to care for members with complex needs, especially for those with chronic conditions. The goal is to keep our members in the community with the resources necessary to maintain the highest functional status possible. • Arrangements for durable medical equipment (DME) What the UnitedHealthcare Community Plan and ancillary services as needed or ordered by the case manager can provide for your patients? care provider • Telephone contact with members and facilitation of • Outreach to members to promote assistance with home visits keeping doctor’s appointments • Health education and educational materials • Work with members to identify and address barriers • A health assessment with stratification of diagnosis to seeking health care and to following their medical and severity of condition and psychosocial needs treatment plan of care • Referral to community resources as needed For more information or to make a referral, • Assistance with medical transportation call 877-542-9235 . Clinical Guidelines Clinical Practice Guidelines (CPG) are available at UHCprovider.com > Menu > Health Plans by State > Select State > Medicaid (Community Plan) > Policies and Clinical Guidelines. Guidelines are available for diabetes, asthma, perinatal care, preventive services, ADHD, depression and many other conditions. Click on your appropriate state and there will be a link to the currently approved guidelines or call for a copy. 877-542-9235 UHCprovider.com 29 | For more information, call 877-842-3210 or visit .

30 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan Cultural Competence We work to try to identify gaps in care related to a member’s language and cultural needs. To help reduce those gaps and improve culturally competent care, we’re reminding care providers that UnitedHealthcare Community Plan’s members have a right to receive care that is culturally appropriate and respects their cultural and ethnic background and origins. Upon enrollment, information on a member’s primary If you need assistance in communicating with one of our members, you may call . 877-542-9235 language is obtained and members may receive assistance in choosing a primary care provider who will meet their needs. UnitedHealthcare Community Plan provides access to a language line for translation of communications for our non-English speaking members. The language line is available to help ensure that the cultural, ethnic and linguistic needs of our members are being met. Pharmacy Updates As a reminder, pharmacy updates are available online at > Menu > Health Plans by State > UHCprovider.com Select State > Medicaid (Community Plan) > Pharmacy Resources and Physician Administered Drugs. You’ll find: • A list of covered pharmaceuticals, including restrictions and preferences • Pharmaceutical management procedures • Explanations on limits or quotas • How to submit and support special requests • Generic substitution, therapeutic interchange and step-therapy protocols 877-542-9235 For more information, call . 30 | For more information, call 877-842-3210 or visit UHCprovider.com .

31 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan Site of Care Medical Necessity Reviews and Revised Prior Authorization Requirements for Speech, Occupational, and Physical Therapy Services — Effective May 13, 2019 UnitedHealthcare Community Plan of Florida aims to improve cost efficiencies for the overall health care system. One way we’ll do that is by conducting site of care medical necessity reviews for all speech, occupational and physical therapy services. We’re also revising our existing prior authorization requirements. Site of care reviews will apply to all speech, occupational Site of Care Medical Necessity Reviews and physical therapy procedure codes that are currently For dates of service on or after May 13, 2019, once subject to prior authorization requirements. You can find prior authorization for speech, occupational, or physical the list of services that are subject to prior authorization therapy services is requested in accordance with our UHCprovider.com/FLcommunityplan requirements at prior authorization requirements, we’ll determine whether > Prior Authorization and Notification > UnitedHealthcare the site of care is medically necessary, including cost Community Plan Prior Authorization Requirements. effective, consistent with Florida’s Agency for Health Care Administration (AHCA) definition of medical necessity. Site Prior Authorization Requirement Changes of care reviews will be conducted only if the service will be For dates of service on or after May 13, 2019, we’re performed in an outpatient hospital. making the following changes to our prior authorization The utilization review guideline we use to help facilitate requirements for speech, occupational and physical our site of care medical necessity determinations therapy services: for these therapy services will be available at • In order to support the physician’s role in managing UHCprovider.com/policies > Community Plan Policies member care, the member’s primary care provider > Medical & Drug Policies and Coverage Determination (PCP) will be required to submit prior authorization Guidelines for Community Plan > Outpatient Speech, requests for evaluations and re-evaluations. Currently, Occupational and Physical Therapy — Site of Care (for these types of prior authorization requests for therapy Florida Only). services are often submitted by therapy providers. Site of care reviews will apply to the following UnitedHealthcare Community Plan of Florida benefit plans: • Florida M*Plus Managed Medical Assistance (MMA) Medicaid benefit plans • Florida Healthy Kids (FHK) CONTINUED > 31 | For more information, call 877-842-3210 or visit . UHCprovider.com

32 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan < CONTINUED Site of Care Medical Necessity Reviews and Revised Prior Authorization Requirements for Speech, Occupational, and Physical Therapy Services — Effective May 13, 2019 As a reminder, please complete the prior authorization • We will require that additional documentation be submitted to us as part of the prior authorization process in one of the following ways: process for evaluations and re-evaluations. The • Online: Use the Prior Authorization and Notification additional documentation requirements can . UHCprovider.com/paan tool on Link at be found in the utilization review guideline at 877-470-7613 • Fax: > Community Plan UHCprovider.com/policies Policies > Medical & Drug Policies and Coverage We’re here to help. If you have additional Determination Guidelines for Community Plan > . questions, please call us at 877-842-3210 Outpatient Speech, Occupational and Physical Therapy Services (for Florida Only). Appointment Availability Standards As a reminder, UnitedHealthcare Community Plan has appointment availability requirements for primary care physicians and specialists. The requirements apply to routine, urgent and after-hours care. For specific UHCprovider.com/guides information, please refer to your Provider Administrative Manual online at . 32 | For more information, call 877-842-3210 or visit UHCprovider.com .

33 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan UnitedHealthcare Community Plan Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates For complete details on the policy updates listed in the following table, please refer to the April 2019 Medical Policy Update Bulletin at UHCprovider.com > Policies and Protocols > Community Plan Policies > Medical & Drug Policies and Coverage . Determination Guidelines > Medical Policy Update Bulletins Policy Type Effective Date Policy Title NEW Preimplantation Genetic Testing Medical July 1, 2019 UPDATED/REVISED April 1, 2019 Drug Actemra® (Tocilizumab) Injection for Intravenous Infusion April 1, 2019 Medical Bone or Soft Tissue Healing and Fusion Enhancement Products CDG June 1, 2019 Breast Reconstruction Post Mastectomy CDG June 1, 2019 Breast Repair/Reconstruction Not Following Mastectomy Medical July 1, 2019 Chromosome Microarray Testing (Non-Oncology Conditions) April 1, 2019 Medical Cochlear Implants Medical April 1, 2019 Computerized Dynamic Posturography Drug April 1, 2019 Denosumab (Prolia® & Xgeva®) April 1, 2019 Medical Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Medical July 1, 2019 Electroencephalographic (EEG) Monitoring and Video Recording Medical April 1, 2019 Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome Medical June 1, 2019 Fecal Calprotectin Testing Medical June 1, 2019 Gastrointestinal Motility Disorders, Diagnosis and Treatment June 1, 2019 Drug Infliximab (Remicade®, Inflectra™, Renflexis™) (for Iowa and Louisiana Only) Infliximab (Remicade®, Inflectra™, Renflexis™) (for States Other Than Drug June 1, 2019 Iowa and Louisiana) June 1, 2019 Medical Intrauterine Fetal Surgery CONTINUED > UHCprovider.com 33 | For more information, call 877-842-3210 or visit .

34 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Community Plan < CONTINUED UnitedHealthcare Medical Policy, Medical Benefit Drug Policy and Coverage Determination Guideline Updates Policy Type Effective Date Policy Title UPDATED/REVISED April 1, 2019 Drug Ketamine Molecular Oncology Testing for Cancer Diagnosis, Prognosis, April 1, 2019 Medical and Treatment Decisions Medical April 1, 2019 Occipital Neuralgia and Headache Treatment April 1, 2019 Drug Ocrevus™ (Ocrelizumab) Drug April 1, 2019 Ophthalmologic Policy: Vascular Endothelial Growth Factor (VEGF) Inhibitors April 1, 2019 Drug Orencia® (Abatacept) Injection for Intravenous Infusion April 1, 2019 CDG Orthognathic (Jaw) Surgery April 1, 2019 CDG Pectus Deformity Repair Drug April 1, 2019 Rituximab (Rituxan® & Truxima®) April 1, 2019 Drug Simponi Aria® (Golimumab) Injection for Intravenous Infusion Drug April 1, 2019 Stelara® (Ustekinumab) Medical April 1, 2019 Thermography Drug April 1, 2019 Trogarzo™ (Ibalizumab-Uiyk) Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. or visit 34 | For more information, call . UHCprovider.com 877-842-3210

35 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Medicare Advantage Learn about Medicare policy and guideline changes. UnitedHealthcare Medicare UnitedHealthcare Medicare Advantage Policy Guideline Advantage Coverage Updates Summary Updates UHCprovider.com 35 | For more information, call 877-842-3210 or visit .

36 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Medicare Advantage UnitedHealthcare Medicare Advantage Policy Guideline Updates The following UnitedHealthcare Medicare Advantage Policy Guidelines have been updated to reflect the most current clinical coverage rules and guidelines developed by the Centers for Medicare & Medicaid Services (CMS). The updated policies are UHCprovider.com > Menu > Policies and Protocols > available for your reference at . Medicare Advantage Policies > Policy Guidelines Policy Title UPDATED/REVISED (Approved on March 13, 2019) Capsule Endoscopy Category III CPT Codes Chiropractic Services Colonic Irrigation (NCD 100.7) Coronary Fractional Flow Reserve Using Computed Tomography (FFR-ct) Gastric Freezing (NCD 100.6) Gravlee Jet Washer (NCD 230.5) Implantation of Anti-Gastroesophageal Reflux Device (NCD 100.9) Laboratory Tests – CRD Patients (NCD 190.10) Melodic Intonation Therapy (NCD 170.2) Molecular Diagnostic Infectious Disease Testing Molecular Pathology/Molecular Diagnostics/Genetic Testing Percutaneous Coronary Interventions Percutaneous Image-Guided Breast Biopsy (NCD 220.13) Positron Emission Tomography (PET) Scan (Including NCDs 220.6-220.6.20) Serologic Testing for Acquired Immunodeficiency Syndrome (AIDS) (NCD 190.9) Therapeutic Embolization (NCD 20.28) Transcatheter Aortic Valve Replacement (TAVR) (NCD 20.32) Transcranial Magnetic Stimulation CONTINUED > UHCprovider.com 36 | For more information, call 877-842-3210 or visit .

37 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Medicare Advantage < CONTINUED UnitedHealthcare Medicare Advantage Policy Guideline Updates Policy Title UPDATED/REVISED (Approved on March 13, 2019) Transmyocardial Revascularization (TMR) (NCD 20.6) Vertebral Axial Decompression (VAX-D) (NCD 160.16) Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. 37 | For more information, call . or visit UHCprovider.com 877-842-3210

38 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Medicare Advantage UnitedHealthcare Medicare Advantage Coverage Summary Updates For complete details on the policy updates listed in the following table, please refer to the April 2019 Medicare Advantage Coverage Summary Update Bulletin at UHCprovider.com > Menu > Policies and Protocols > Medicare Advantage . Policies > Coverage Summaries > Coverage Summary Update Bulletins Policy Title UPDATED/REVISED (Approved on March 19, 2019) Allergy Testing and Allergy Immunotherapy Artificial Disc Replacement, Cervical and Lumbar Bone Density Studies/Bone Mass Measurements Brachytherapy Procedures Cardiovascular Diagnostic Procedures Chelation Therapy Chiropractic Services Complementary and Alternative Medicine Computed Tomographic Angiography (CTA)/Electron Beam Computed Tomography (EBCT) of the Chest Cosmetic and Reconstructive Procedures Durable Medical Equipment (DME), Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid Gastroesophageal and Gastrointestinal (GI) Services and Procedures Incontinence: Urinary and Fecal Incontinence, Diagnosis and Treatments Maternity and Newborn Care Medications/Drugs (Outpatient/Part B) Mental Health Services and Procedures Nasal and Sinus Procedures Pain Management and Pain Rehabilitation Percutaneous Transluminal Angioplasty and Stenting Radiologic Therapeutic Procedures CONTINUED > UHCprovider.com 877-842-3210 or visit 38 | For more information, call .

39 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Medicare Advantage < CONTINUED UnitedHealthcare Medicare Advantage Coverage Summary Updates Policy Title UPDATED/REVISED (Approved on March 19, 2019) Transmyocardial Revascularization (TMR) Ventriculectomy, Partial Vision Services, Therapy and Rehabilitation Wound Treatments Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. 39 | For more information, call or visit . UHCprovider.com 877-842-3210

40 UnitedHealthcare Network Bulletin May 2019 Table of Contents Doing Business Better Learn about how we make improved health care decisions. 2018 Quality Improvement Collaboration between Primary Care Physicians and Program Overview Behavioral Health Clinicians UnitedHealthcare maintains a Can Make a Difference Quality Improvement program to improve our members’ and care When a member receives providers’ health care experience. services from more than one In 2018, the program helped care provider, the care providers support delivery of evidence- should collaborate and coordinate based care and monitoring and effectively to help ensure care is improving clinical performance and comprehensive, safe and effective. service measures, among other Lack of communication may improvements. negatively affect quality patient care. Continuity and coordination of care takes on greater importance for patients with severe and persistent mental health and/or substance use conditions. UHCprovider.com or visit 877-842-3210 40 | For more information, call .

41 UnitedHealthcare Network Bulletin Table of Contents May 2019 Doing Business Better Collaboration between Primary Care Physicians and Behavioral Health Clinicians Can Make a Difference When a member receives services from more than one care provider, the care providers should collaborate and coordinate effectively to help ensure care is comprehensive, safe and effective. Lack of communication may negatively affect quality patient care. For example, members with medical illnesses may also have mental health or substance use conditions. Continuity and coordination of care takes on greater importance for patients with severe and persistent mental health and/or substance use conditions. This is also true when medications are prescribed, when there are co-existing medical/psychiatric symptoms or when patients have been hospitalized for a medical or psychiatric condition. Discuss with your patients the benefits of sharing essential clinical information with their behavioral health clinician. When applicable, we encourage you to obtain a signed release from each UnitedHealthcare member that allows you to share appropriate treatment information with the member’s behavioral health clinician. UHCprovider.com 41 | For more information, call 877-842-3210 or visit .

42 UnitedHealthcare Network Bulletin May 2019 Table of Contents Doing Business Better 2018 Quality Improvement Program Overview UnitedHealthcare maintains a Quality Improvement (QI) program to improve our members’ and providers’ health care experience. In 2018, the program included these important activities: • Throughout the year, we contacted members who Supporting Delivery of Evidence-Based Care may be overdue for needed care, suggesting that they • We informed our network physicians about their contact their doctor for tests or treatment. patients who might need care like cancer screening or diabetes tests. Monitoring and Improving Clinical • We encouraged doctors and other health care Performance and Service Measures professionals to provide the care according to We monitored all aspects of quality, including but not the most current scientific evidence (“evidence- limited to Healthcare Effectiveness Data and Information based medicine”). For example, we offered website Set (HEDIS®), Consumer Assessment of Healthcare links to nationally accepted guidelines from the Providers and Systems (CAHPS®) measures and quality of American Diabetes Association, the American Heart care issues, access, availability and member/practitioner Association, American College of Cardiology, United satisfaction. Opportunities were identified and actions States Preventive Services Task Force and other were taken where appropriate. organizations. We monitored performance against these clinical guidelines. Results on key clinical performance measures are shown in the following chart: Measure UnitedHealthcare National Mean Trend Point QC 2016 2017 2018 Change Percentile 70.26 – – 25th Breast Cancer Screening – Cervical Cancer Screening 74.46 74.94 2.0 75th 72.98 Childhood Immunization Status — Combo 10 48.6 50.51 52.36 3.8 25th Colorectal Cancer Screening – 59.83 61.65 – 50th Comprehensive Diabetes Care — Blood Pressure 55.94 57.87 65.09 50th 9.1 Control (<140/90) Comprehensive Diabetes Care — Eye Exams 47.41 46.77 48.35 0.9 25th 50th 5.6 58.74 55.55 53.19 Comprehensive Diabetes Care — HbA1c Control (<8%) 50.99 Controlling High Blood Pressure 52.36 56.47 5.5 25th 50th 7.4 71.87 77.08 69.73 Prenatal and Postpartum Care — Postpartum Care *HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA). *CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ). CONTINUED > . 42 | For more information, call 877-842-3210 or visit UHCprovider.com

43 UnitedHealthcare Network Bulletin Table of Contents May 2019 Doing Business Better < CONTINUED 2018 Quality Improvement Program Overview Concerning our utilization management processes, the Measuring Member Experience most recent analysis showed improvement in provider We annually measure member experience using the satisfaction with: CAHPS survey tool. The most recent member satisfaction • Ease and timeliness of notification/prior authorization results showed improvement in: processes for radiology procedures and services • Claims processing • Ease and timeliness of clinical review process for • Customer service radiology, inpatient and outpatient procedures • Getting care quickly • Ease of the appeal process CAHPS measures identified as potential opportunities for Efforts are under way to improve performance related to: improvement were: • Simplifying the prior authorization process • Rating of health plan • Improving matching prior authorization with claims • Rating of the specialist • Reducing prior authorization turn-around times • Rating of health care • Improving the efficiency and ease of physician-to- For the marketplace, we measure member experience physician communications using the Key Member Indicator (KMI) Survey and • Reducing the amount of clinical documentation QHP Enrollee Survey. The most recent surveys show required for a prior authorization improvements in: • Customer Service Accreditation KMI Survey and QHP Enrollee Survey measures identified The National Committee for Quality Assurance (NCQA) as potential opportunities for improvement were: Health Plan Accreditation is a nationally recognized • Customer Service evaluation that purchasers, regulators and patients can use to assess health plans. Many of UnitedHealthcare’s • Getting Care Quickly commercial plans held NCQA accreditation in 2018. • Getting Needed Care Visit NCQA’s web site to see our health plans’ current accreditation statuses at ncqa.org . UnitedHealthcare Measuring Provider Experience also maintained URAC Health Utilization Management We conducted a Physician and Practice Manager survey accreditation. to measure provider satisfaction. Results from the most recent survey showed improvement of five points or Credentialing of Network Providers greater in: In compliance with governmental and NCQA • Overall service satisfaction requirements, UnitedHealthcare assesses the credentials • Timeliness of prior authorizations of all doctors and key health care professionals who participate in our networks. Assessments are conducted • Ease of the appeal process before the professional is added to our network and on a • Timeliness of the appeals process regular basis after joining. . UHCprovider.com or visit 877-842-3210 43 | For more information, call

44 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates Learn about updates with our company partners. Oxford® Medical and Reminder for Your Patients New York & Connecticut Administrative Policy Participating Provider in UnitedHealthcare Oxford Laboratory and Pathology Updates Commercial Plans Protocol Penalty Update, In December 2017, we let care Effective Aug. 1, 2019 providers know that we would UnitedHealthcare West be taking steps to streamline The New York & Connecticut Medical Management the administrative experience Participating Provider Laboratory Guideline Updates for UnitedHealthcare Oxford and Pathology Protocol requires commercial plans. These steps have the use of participating laboratory begun and will continue over the and pathology providers, unless UnitedHealthcare West next 24 to 36 months as employer the member agrees, in writing, in groups renew health coverage for Benefit Interpretation Policy advance, on Oxford’s Consent Form their employees. Updates to use a nonparticipating lab or pathologist. If the member elects to use a non-participating provider, the claim will be paid according to their benefits, out-of-network or denied, if the member does not have out-of-network benefits. As of Aug. 1, 2019, if the participating provider does not submit a copy of the signed Consent Form, within 15 days of the request, Oxford will administratively deny the participating provider’s claim. . UHCprovider.com or visit 877-842-3210 44 | For more information, call

45 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates Reminder for Your Patients in UnitedHealthcare Oxford Commercial Plans In December 2017, we let care providers know that we would be taking steps to streamline the administrative experience for UnitedHealthcare Oxford commercial plans. These steps have begun and will continue over the next 24 to 36 months as employer groups renew health coverage for their employees If you have patients whose employers are renewing their When your patients see you for care, ask your staff to: health coverage with a UnitedHealthcare Oxford commercial • Check their eligibility each time they visit your office. plan, you’ll see some differences in their new member • Include their new member ID number on claims or identification (ID) card that we want to remind you about: requests for services that require authorization. • The member’s ID number will be digits 11 • Use the provider website listed on the back of the numeric-only • The Group Number will change to be . member’s ID card for secure transactions. • The website listed on the back of the card is For more information about these changes, use . UHCprovider.com this and share it with Quick Reference Guide • The ERA Payer ID number will not change and will your staff. Or you may call Provider Services at . remain 06111 800-666-1353 . When you call, provide your National Provider Identifier (NPI) number. UHCprovider.com . 45 | For more information, call or visit 877-842-3210

46 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates New York & Connecticut Participating Provider Laboratory and Pathology Protocol Penalty Update, Effective Aug. 1, 2019 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. If the member elects to use a non-participating provider, the claim will be paid according to their benefits, out-of-network or denied, if the member does not have out-of-network benefits. A complete list of participating laboratories and As of Aug. 1, 2019, if the participating provider does not submit a copy of the signed Consent Form, within 15 pathologists can be found in our Provider Directory. days of the request, Oxford will administratively deny the participating provider’s claim. Any payment previously made will be subject to recovery. In these instances, the participating provider is prohibited from balance billing the member. 877-842-3210 UHCprovider.com 46 | For more information, call or visit .

47 UnitedHealthcare Network Bulletin May 2019 Table of Contents UnitedHealthcare Affiliates Oxford® Medical and Administrative Policy Updates For complete details on the policy updates listed in the following table, please refer April 2019 Policy Update Bulletin to the OxfordHealth.com > Providers > at Tools & Resources > Medical Information > Medical and Administrative Policies > Policy Update Bulletin . Policy Title Policy Type Effective Date NEW Clinical June 1, 2019 Preimplantation Genetic Testing UPDATED/REVISED Abortions (Therapeutic and Elective) Administrative April 1, 2019 April 1, 2019 Administrative Accreditation Requirements for Radiology Services Clinical May 1, 2019 Actemra® (Tocilizumab) Injection for Intravenous Infusion Assisted Administration of Clotting Factors, Coagulant Blood Products Clinical April 1, 2019 & Other Hemostatics April 1, 2019 Bone or Soft Tissue Healing and Fusion Enhancement Products Clinical Clinical May 1, 2019 Breast Reconstruction Post Mastectomy May 1, 2019 Clinical Breast Repair/Reconstruction Not Following Mastectomy Cardiology Procedures Requiring Precertification for eviCore April 1, 2019 Clinical healthcare Arrangement Care Plan Oversight Reimbursement April 1, 2019 Chromosome Microarray Testing (Non-Oncology Conditions) Clinical June 1, 2019 Clotting Factors, Coagulant Blood Products & Other Hemostatics Clinical April 1, 2019 Clinical April 1, 2019 Cochlear Implants Complement Inhibitors (Soliris® & Ultomiris™) Clinical July 1, 2019 April 1, 2019 Clinical Computerized Dynamic Posturography Denosumab (Prolia® & Xgeva®) Clinical May 1, 2019 May 1, 2019 Clinical Drug Coverage Criteria – New and Therapeutic Equivalent Medications CONTINUED > . UHCprovider.com or visit 877-842-3210 47 | For more information, call

48 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates < CONTINUED Oxford® Medical and Administrative Policy Updates Policy Title Policy Type Effective Date UPDATED/REVISED Clinical Drug Coverage Guidelines April 1, 2019 Drug Coverage Guidelines Clinical May 1, 2019 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Clinical April 1, 2019 Clinical Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome April 1, 2019 Exondys 51® (Eteplirsen) April 1, 2019 Clinical Fecal Calprotectin Testing Clinical April 7, 2019 Gastrointestinal Motility Disorders, Diagnosis and Treatment Clinical May 1, 2019 Infliximab (Remicade®, Inflectra™, Renflexis™) Clinical April 1, 2019 Intrauterine Fetal Surgery Clinical May 1, 2019 Maximum Frequency Per Day Reimbursement May 1, 2019 May 1, 2019 Maximum Frequency Per Day (CES) Reimbursement Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Clinical April 1, 2019 Treatment Decisions Clinical Obstetrical Ultrasonography April 1, 2019 Occipital Neuralgia and Headache Treatment Clinical April 1, 2019 Clinical Ocrevus™ (Ocrelizumab) May 1, 2019 Once in a Lifetime Procedures Reimbursement May 1, 2019 Orencia® (Abatacept) Injection for Intravenous Infusion Clinical May 1, 2019 Oxford's Outpatient Imaging Self-Referral Clinical April 1, 2019 Par Gastroenterologists Using Non-Par Anesthesiologists: In-Office & May 1, 2019 Administrative Ambulatory Surgery Centers Pectus Deformity Repair Clinical April 1, 2019 Precertification Exemptions for Outpatient Services Administrative May 1, 2019 Radiology Procedures Requiring Precertification for eviCore healthcare Clinical April 1, 2019 Arrangement Rituximab (Rituxan® & Truxima®) Clinical April 1, 2019 May 1, 2019 Rituximab (Rituxan® & Truxima®) Clinical CONTINUED > UHCprovider.com or visit 877-842-3210 48 | For more information, call .

49 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates < CONTINUED Oxford® Medical and Administrative Policy Updates Policy Type Effective Date Policy Title UPDATED/REVISED Clinical Rituximab (Rituxan® & Truxima®) July 1, 2019 Simponi Aria® (Golimumab) Injection for Intravenous Infusion Clinical May 1, 2019 Stelara® (Ustekinumab) Clinical May 1, 2019 Thermography April 1, 2019 Clinical Trogarzo™ (Ibalizumab-Uiyk) Clinical April 1, 2019 Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that Oxford provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. Oxford HMO products are underwritten by Oxford Health Plans (CT), Inc. and Oxford Health Plans (NJ), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. or visit . 877-842-3210 49 | For more information, call UHCprovider.com

50 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates UnitedHealthcare West Medical Management Guideline Updates For complete details on the policy updates listed in the following table, please refer to April 2019 UnitedHealthcare West Medical Management Guidelines Update the UHCprovider.com > Policies and Protocols > Commercial Policies > at Bulletin UnitedHealthcare West Medical Management Guidelines > Medical Management Guideline Update Bulletins . Policy Title Effective Date NEW Preimplantation Genetic Testing June 1, 2019 UPDATED/REVISED Attended Polysomnography for Evaluation of Sleep Disorders April 1, 2019 Bone or Soft Tissue Healing and Fusion Enhancement Products April 1, 2019 May 1, 2019 Breast Reconstruction Post Mastectomy May 1, 2019 Breast Repair/Reconstruction Not Following Mastectomy Chromosome Microarray Testing (Non-Oncology Conditions) June 1, 2019 April 1, 2019 Cochlear Implants April 1, 2019 Computerized Dynamic Posturography April 1, 2019 Electrical Stimulation for the Treatment of Pain and Muscle Rehabilitation Embolization of the Ovarian and Iliac Veins for Pelvic Congestion Syndrome April 1, 2019 April 7, 2019 Fecal Calprotectin Testing Gastrointestinal Motility Disorders, Diagnosis and Treatment May 1, 2019 Intrauterine Fetal Surgery May 1, 2019 April 1, 2019 Molecular Oncology Testing for Cancer Diagnosis, Prognosis, and Treatment Decisions April 1, 2019 Occipital Neuralgia and Headache Treatment Pectus Deformity Repair May 1, 2019 Thermography April 1, 2019 The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that Note: UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. or visit 50 | For more information, call . UHCprovider.com 877-842-3210

51 UnitedHealthcare Network Bulletin Table of Contents May 2019 UnitedHealthcare Affiliates UnitedHealthcare West Benefit Interpretation Policy Updates For complete details on the policy updates listed in the following table, please refer to the April 2019 UnitedHealthcare West Benefit Interpretation Policy Update at UHCprovider.com > Policies and Protocols > Commercial Policies > Bulletin UnitedHealthcare West Benefit Interpretation Policies > Benefit Interpretation Policy Update Bulletins . Policy Title UPDATED/REVISED (Effective May 1, 2019) Family Planning: Birth Control Genetic Testing Note: The inclusion of a health service (e.g., test, drug, device or procedure) on this list does not imply that UnitedHealthcare provides coverage for the health service. In the event of an inconsistency or conflict between the information in this bulletin and the posted policy, the provisions of the posted policy prevail. or visit 51 | For more information, call . UHCprovider.com 877-842-3210

52 UnitedHealthcare Network Bulletin Table of Contents May 2019 State News Stay up to date with the latest state/regional news. Participating Provider Site of Care Medical New York & Connecticut Laboratory and Pathology Necessity Reviews and Participating Provider Protocol Revised Prior Authorization Laboratory and Pathology Requirements for Speech, Protocol Penalty Update, UnitedHealthcare and UnitedHealthcare Oxford require Occupational, and Physical Effective Aug. 1, 2019 physicians and other qualified health Therapy Services — The New York & Connecticut care professionals to inform patients Effective May 13, 2019 Participating Provider Laboratory when referring them to or including and Pathology Protocol requires UnitedHealthcare Community Plan an out-of-network care provider in the use of participating laboratory of Florida aims to improve cost the patient’s health plan. To help and pathology providers, unless efficiencies for the overall health that disclosure process and save the member agrees, in writing, in care system. One way we’ll do members potential costs from using advance, on Oxford’s Consent that is by conducting site of care an out-of-network care provider, Form to use a nonparticipating lab medical necessity reviews for all beginning June 1, 2019, network or pathologist. If the member elects speech, occupational and physical care providers in Connecticut to use a non-participating provider, therapy services. We’re also revising and Maryland must obtain the claim will be paid according our existing prior authorization consent from UnitedHealthcare or to their benefits, out-of-network or requirements. For dates of service UnitedHealthcare Oxford members denied, if the member does not have on or after May 13, 2019, once before referring them to or using out-of-network benefits. As of Aug. prior authorization for speech, out-of-network laboratories and 1, 2019, if the participating provider occupational, or physical therapy pathologists for their care. does not submit a copy of the signed services is requested in accordance Consent Form, within 15 days of the with our prior authorization request, Oxford will administratively requirements, we’ll determine Prior Authorization deny the participating provider’s whether the site of care is medically Required for Therapeutic claim. necessary, including cost effective, Radiopharmaceuticals consistent with Florida’s Agency for Effective Aug. 1, 2019, Health Care Administration (AHCA) UnitedHealthcare will require definition of medical necessity. Site prior authorization for therapeutic of care reviews will be conducted radiopharmaceuticals administered only if the service will be performed on an outpatient basis for in an outpatient hospital. UnitedHealthcare Community Plan members in Mississippi and Tennessee. UHCprovider.com . 877-842-3210 52 | For more information, call . or visit or visit 877-842-3210 52 | For more information, call UHCprovider.com

53 UnitedHealthcare Network Bulletin Table of Contents May 2019 Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc., or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, Inc., Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. Doc#: PCA-1-015515-04112019_04192019 CPT® is a registered trademark of the American Medical Association. © 2019 United HealthCare Services, Inc. UHCprovider.com 53 | For more information, call 877-842-3210 . or visit

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