Dear Valued Network Physician:

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1 <Date> <Name> <Address 1> <Address > <City>, <State> <Zip> Radiation Oncology As announced on July 1, 009 on OxfordHealth.com and UnitedHealthcareOnline.com, medical coverage reviews for radiation therapy services will begin November 1, 009 for UnitedHealthcare products and December 1, 009 for Oxford products. New York and Connecticut: If a treating physician does not advance notify UnitedHealthcare prior to administering IMRT, or does not receive an authorization number from Oxford for radiation therapy codes, claims may not be reimbursed. UnitedHealthcare Insurance Company products issued in New Jersey are not included in the Radiation Therapy/IMRT Notification Program. Oxford's New Jersey small group and individual products do not require precertification or prior notice for these services. However, they are subject to medical necessity review post -service. At your option, you may request a review prior to service. There is no penalty if you choose not to request a pre-service review. The Oxford pilot program applies to both Commercial and Medicare products. Dear Valued Network Physician: We value our relationship with you, and we appreciate the care you provide to the people we insure. At UnitedHealthcare, we strive to have consistency among our different insurance products so that we can work together as efficiently as possible. We are making progress in this effort; however, due to the differing structure of our insurance offerings, there will occasionally be some differences which we are working expeditiously to resolve. In response to significant observed variation from evidence-based standards, professional society guidance and local peerperformance, UnitedHealthcare has determined the need for medical coverage reviews for some important therapeutic interventions. Radiation therapy, including Intensity Modulated Radiation Therapy (IMRT), is one of these interventions and is the subject of this letter. This is an opportunity to enhance quality and appropriateness in clinical care delivery. Effective November 1, 009, UnitedHealthcare and all UnitedHealthcare affiliate companies will adopt an updated IMRT policy. UnitedHealthcare will require advance notification for all IMRT services on or after November 1, For Oxford products, effective December 1, 009, we will pilot a precertification and medical necessity review program for all therapeutic radiology services. The IMRT policy and Oxford pilot program details are available online at UnitedHealthcareOnline.com and OxfordHealth.com, respectively. We expect to combine unique elements over time as we evaluate the results of UnitedHealthcare advance notification requirements and the Oxford pilot. We have partnered with CareCore National, LLC for clinical review of cases based upon their expertise in administering similar programs and their record of working effectively with the physician community. To ensure that the radiation therapy criteria utilized in our program and cases reviewed by CareCore radiation oncologists are consistent with specialty society guidance and current clinical evidence, we have solicited comments from our 1 UnitedHealthcare Insurance Company products issued in New Jersey are not included. Oxford small and individual products issued in New Jersey do not require precertification, but do require medical necessity review which may be requested prior to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to rendering the service. Doc #: UHC0094 MS

2 external oncology expert advisory board, CareCore s radiation oncology board and relevant medical specialty societies. This coverage criterion is available on the Web sites noted above. The Oxford pilot program will help us further understand how we can improve the process of approving coverage for radiation oncology services. To assist you with simplifying your administration in preparing advance notification or medical necessity review for applicable services handled for your UnitedHealthcare and Oxford patients, we have created the enclosed Quick Reference Guide and Referral Process Guide. Thank you for being a valued member of our network and working with us to provide coordinated care services to our members and your patients. Sincerely, Sanford Cohen, MD Chief Medical Officer, Northeast Region Lee Newcomer, MD Senior Vice President, Oncology Doc #: UHC0094 MS

3 Radiation Oncology Quick Reference Guide for UnitedHealthcare and Oxford patients UnitedHealthcare 1 Oxford Policy applicable to Codes requiring review Process and Information CMS 1500 submissions 77301, 77418, 0073T IMRT Data Collection Form at UnitedHealthcareOnline.com > Clinician Resources > Cancer Oncology > IMRT > Related Links. All CMS 1500, UB-9 and UB-94 submissions, participating and nonparticipating CPT Codes: 55875, 55876, 5590, 76950, 76965, 77011, 77014, (excluding CPT ), 0073T, 018T, 0197T, C1715-C1719, C178, C634-C643, C698-C699, C975, C976, C978, G0173, G051, G0339 and G0340, S8030 and Q3001. Rev codes: 330, 333, 339, 344, 973 Radiation Therapy Physician Worksheets at CareCoreNational.com > Provider Resources > Provider Tools > Submit Requests to Fax: (866) Online: CareCoreNational.com Phone: (877) EDI Claims Submission Paper Claims Submission Payer ID: 3906 Payer ID: UnitedHealth Integrated Services P.O. Box Salt Lake City, UT UnitedHealthcare Insurance Company products issued in New Jersey are not included. Oxford Claims Department P.O. Box 708 Bridgeport, CT Oxford small and individual products issued in New Jersey do not require precertification, but do require medical necessity review, which may be requested prior to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to rendering the service.

4 Radiation Oncology Notification Review Process for UnitedHealthcare products For your UnitedHealthcare patients, advance notification is required prior to initiating therapy for all members 1, requiring IMRT services that will be billed on a CMS 1500 Health Claim Insurance form. Beginning November 1, 009, the CPT codes requiring advance notification include: Intensity modulated radiotherapy plan Intensity modulated treatment delivery, single or multiple fields/arcs, per treatment session 0073T Compensator-based beam modulation treatment delivery 1. Proper notification will require a completed IMRT Data Collection form which is available at UnitedHealthcareOnline.com > Clinician Resources > Cancer Oncology > IMRT > Related Links. Information requested will include: Member name and number, physician and facility demographics information, diagnosis and ICD-9 code, anticipated date of IMRT plan and anticipated start date of therapy. For conditions where IMRT is not considered proven by the policy, additional clinical information will be required (please reference below). Only the upper section of the IMRT Data Collection Form is required for adult patients (older than 19 years of age) with a proven diagnosis according to the IMRT medical policy, and all pediatric patients (under age 19). The entire IMRT Data Collection form must be completed for all adult cases without proven diagnoses according to the IMRT medical policy.. After completion of the IMRT Data Collection form, please fax the form and all supporting information toll-free to (866) You will be notified that the form was received, and, if the first date of service is within seven business days, you will be notified by phone of the outcome of the submission. 3. The medical policy listing conditions and diagnoses that are covered is available at UnitedHealthcareOnline.com > Clinician Resources > Cancer Oncology. 4. Radiation therapy care started prior to and continuing after November 1, 009 does NOT require notification. 1 Services provided to members who have UnitedHealthcare as their secondary insurer do not require advanced notification for IMRT services. UnitedHealthcare Insurance Company products issued in New Jersey are not included.

5 Claims processing UnitedHealthcare will continue to process claims from participating physicians and other health care professionals for radiation therapy services for UnitedHealthcare products. You will receive payment directly from us. Please continue to submit claims electronically to our Payer ID #3906, or by mail to the following address: UnitedHealth Integrated Services P.O. Box Salt Lake City, UT

6 Radiation Oncology Medical Necessity Review Process for Oxford products For your patients covered by UnitedHealthcare s suite of Commercial and Medicare Oxford products, we have developed the following utilization review process for the administration of radiation therapy services. Precertification based on medical necessity review will be required for accurate claims payment. Beginning December 1, 009, the CPT codes requiring medical necessity review include: 55875, 55876, 5590, 76950, 76965, 77011, 77014, (excluding CPT ), 0073T, 018T, 0197T, C1715-C1719, C178, C634-C643, C698-C699, C975, C976, C978, G0173, G051, G0339 and G0340, S8030 and Q3001. Further, revenue codes 330, 333, 339, 344, 973 are included in the arrangement.. 1. Medical necessity review online or by phone will require the treating physician s office to submit information about their patient s treatment plan as specified in the Radiation Therapy Physician Worksheets. Radiation Therapy Physician Worksheets, to guide offices in gathering the information that will be required for the review, are available on CareCore National s Web site available at CareCoreNational.com > Provider Resources > Provider Tools > Oncology > Radiation Therapy Physician Worksheets.. Physicians and other health care professionals should submit an authorization request either: Online at CareCoreNational.com, or; By calling toll-free at (877) , Monday through Friday, 7 a.m. to 7 p.m. (ET), and Saturday and Sunday, 9 a.m. to 5 p.m. (ET). 3. CareCore National will provide a medical necessity determination response after receipt of all necessary clinical information about the patient s treatment plan as specified in the worksheets. 4. Clinical criteria consistent with existing UnitedHealthcare and Oxford policy are available at CareCoreNational.com, and updated medical policies are available at OxfordHealth.com > Providers > Tools & Resources. Referrals Certain Oxford products require referrals for radiation therapy from the patient s primary care physician. If your patient is enrolled in one of these plans, he/she will be required to obtain a referral Oxford small and individual products issued in New Jersey do not require precertification, but do require medical necessity review, which may be requested prior to service. If a medical necessity review is not requested by the provider prior to service, the medical necessity review will be conducted after the service is rendered with no penalty imposed for failure to request the review prior to rendering the service. 3 Submissions completed online or by telephone will require the physician or other health care professional to submit information about their patient s treatment plan as specified in the Radiation Therapy Physician Worksheets.

7 before seeing you for an initial visit. You can verify your patient s benefit information and if such a referral is required at OxfordHealth.com > Provider > Transactions > Benefits. Claims processing Oxford will continue to process claims from participating physicians and other health care professionals for radiation therapy services. You will receive payment directly from us. Please continue to submit claims electronically to our Payer ID #06111, or by mail to the following address: Oxford Claims Department P.O. Box 708 Bridgeport, CT If a claim is denied because medical necessity was not demonstrated, contract provisions that prohibit balance billing of members will apply. For any service that is not approved for payment, we will offer all appropriate rights of appeal. If you have questions about this program, please call Provider Services toll-free at (800) , and choose option two; or, call CareCore National tollfree at (800) , extension 117. Review process for radiation therapy care started prior to and continuing after December 1, 009 Ongoing episodes of care for Oxford patients must be registered. During the registration process, we will provide you with an authorization number needed for accurate claims payment. The utilization process described above will not apply to these dates of service. Physicians and other health care professionals should call toll-free at (877) to provide the following information: The patient s Oxford identification (ID) number Cancer classification The ordering physician or other health care professional s Oxford ID number Rendering site The date on which treatment began Expected completion date for treatment