Medicare Advantage 2016 Precertification Requirements

Transcription

1 Medicare Advantage 2016 Precertification Requirements (Effective for January 1, 2016 to December 31, 2016) The following Medicare Advantage plans require precertification i from in network providers. Call the telephone number listed on the back of the member s identification card for precertification, verification of member eligibility, benefits and account information. This document provides a general list of all Precertification requirements. Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self- Service Tool within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. Medicare Advantage Plans requiring in-network provider precertification. HMO Plans all contracted network providers. PPO Plans all contracted network providers. PPO Plans all non-contracted out of network providers are encouraged to call Plan States: CA, CO, GA, OH, IN, KY, MO, WI, NY, CT, NH, ME, VA NOTE: There is a national service area for select Employer Group Retiree Medicare Advantage plans. Precertification is the determination that selected medical services meet medical necessity criteria under the member's benefits contract. For the member to receive maximum benefits, the health plan must authorize or precertify these covered services prior to being rendered. Precertification includes a review of both the service and the setting. Care will be covered according to the member's benefits for the services and/or number of days precertified unless our concurrent review determines that additional services and/or days do not qualify for coverage. Certain services may require the member to use a provider designated by the health plan s Utilization Management staff. A copy of the approval will be provided to you, the physician and the hospital or facility. For benefits to be paid the member must be eligible for benefits and the service must be a covered benefit under the contract at the time the services are rendered. Precertification Responsibility For HMO type health plans: It is the participating physician s or provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. The request must come from the provider or facility rendering the service, not the referring physician. If precertification is not obtained, the claim is denied by the Plan and the member must be held harmless. The Precertification number is listed on the back of the member s health plan ID card. For PPO type health plans: It is the network provider s responsibility to contact the health plan s Utilization Management Department to obtain precertification. If precertification is not obtained when the service is from a network provider, the claim is denied by the Plan and the member must be held harmless. Claims from out of network providers will typically pend for a medical necessity review prior to payment if associated with a service in this document. The Precertification number is listed on the back of the member s health plan ID card.

2 Inpatient Admissions Also see Behavioral Health and Transplants sections for precertification requirements. The health plan must be notified of emergency admissions or transfers within 1 business day of admission. Precertification required for non-emergent inpatient transfers between acute facilities. Precertification is required for the following services prior to admission: o Elective Inpatient Admissions o Rehabilitation Facility admissions o Long Term Acute Care (LTAC) o Skilled Nursing Facility admissions Precertification is NOT required, however notice is requested for all members initiating dialysis treatment. Select Outpatient Services: This is not a comprehensive list and is included here as a guide on when to call for precertification. If the service is listed you are required to call for precertification. Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self-Service Tool within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. New in 2016 Oncology (Breast), mrna, Gene Expression Profiling Radiation Therapy Cardiac Catheterization PCI Stent Vascular Angioplasty Vascular Ultrasound Knee and Hip replacements Knee and Spinal Orthoses Vascular Embolization or Occlusion Services Continuing in 2016 Breast Reconstruction Spine Procedures Cervical Fusions Arthroscopies Pacemaker Insertions Endoscopies Hyperbaric Oxygen Therapy Laparoscopies Laminectomies/Laminotomies Tonsillectomy/Adenoidectomy Nerve Destructions

3 Sleep Studies and Sleep Study related equipment and supplies UPPP surgery (Uvulopalatopharyngoplasty - removal of excessive soft tissue in the back of the throat to relieve obstruction) Bariatric/ Gastric Obesity Surgery All potentially Cosmetic surgeries Non-emergent ground, air and water transportation Occupational Therapy Physical Therapy Pain Management Chiropractic Care (New York and Connecticut only) DME/ Prosthetics Precertification is required for the following services (to include, but not limited to). Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self- Service Tool within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. Prosthetics, Orthotics Power Wheelchairs, Accessories, and POV Non-Standard Wheelchairs Non-Standards Beds Patient Transfer Systems Speech Generating Devices and accessories Sleep Study related equipment and supplies Radiology Services Precertification is required for the following services. Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self-Service Tool within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. PET Nuclear Cardiac CT Scan (includes CTA) MRI MRA MRS Echocardiograms Behavioral Health Services Mental Health/ Substance Abuse Services: Specially trained professionals will handle referrals and coordinate care for mental health and substance abuse. This includes: referrals to mental health and substance abuse treatment providers, general information about mental health and substance abuse benefits and treatment, emergency and urgent care information and assistance Plan must be notified of emergency admissions within 1 business day of admission. Precertification is required for:

4 o Inpatient Admissions o Rehabilitation Facility admissions. Rehabilitation requires precertification but benefit availability is limited. Please be sure to check the member s benefits. o Day Hospital admissions o Intensive Outpatient therapy o Psychological and Neuropsychological Testing o Transcranial Magnetic Stimulation (TMS) for depression Transplants: Human Organ and Bone Marrow/ Stem Cell Transplants Precertification is required for Medicare Covered Transplant admissions. All Inpatient admissions for the following: Heart transplant Liver transplant Lung or double lung transplant Simultaneous Pancreas/ Kidney Pancreas transplant Kidney transplant Small bowel transplant Multi-visceral transplant Stem cell/ Bone Marrow transplant (with or without myeloablative therapy) All Outpatient services for the following: Stem Cell/ Bone Marrow transplant (with or without myeloablative therapy) Donor Leukocyte Infusion Specialty Pharmacy Part D drugs - Refer to separate Precertification list. Part B drugs Refer to the Appendix for a general list of drugs paid under the medical benefit requiring precertification. Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self-Service Tool within Availity. Contracted and Noncontracted providers should contact the Health Plan if they are not able to access Availity.

5 APPENDIX This is not a comprehensive list and is included here as a guide on when to call for precertification. If the Part B drug is listed here you are required to call for precertification. The HCPCS code to the Part B drug is the one assigned at the time of this notice. Detailed Prior Authorization requirements are available to the contracted provider by accessing the Provider Self-Service Tool within Availity. Contracted and Non-contracted providers should contact the Health Plan if they are not able to access Availity. HCPCS Code A9699 Drug(s) *Effective date XOFIGO C9025 CYRAMZA 10/1/2015 C9026 ENTYVIO 7/1/2015 C9027 KEYTRUDA C9136 FACTOR VIII C9449 BLINCYTO 11/1/2015 C9455 SYLVANT 1/1/2016 J0129 ABATACEPT, ORENCIA J0135 ADALIMUMAB, HUMIRA PEN J0178 EYLEA J0485 NULOJIX, BELATACEPT 9/1/2015 J0490 BENLYSTA 2/22/2015 J0585 BOTOX, ONABOTULINUMTOXINA J0586 DYSPORT J0587 MYOBLOC J0588 INCOBOTULINUMTOXINA J0881 ARANESP, ARANESP (ALBUMIN FREE), DARBEPOETIN ALFA-POLYSORBATE J0885 EPOETIN ALFA, EPOGEN, PROCRIT J0897 DENOSUMAB, PROLIA, XGEVA J1300 SOLIRIS J1325 FLOLAN, EPOPROSTENOL J1438 ENBREL, ENANERCEPT J1442 FILGRASTIM, NEUPOGEN J1446 GRANIX J1459 PRIVIGEN J1556 BIVIGAM, IVIG J1557 GAMMAPLEX, IMMUNE GLOBULIN J1559 HIZENTRA, IMMUNE GLOBULIN J1561 GAMMAKED, GAMUNEX-C J1566 CARIMUNE NF

6 HCPCS Code J1568 J1569 J1572 J1602 Drug(s) OCTAGAM GAMMAGARD, GAMMAGARD S/D FLEBOGAMMA, IMMUNE GLOBULIN SIMPONI ARIA *Effective date J1740 BONIVA 3/1/2016 J1745 INFLIXIMAB, REMICADE LEUPROLIDE ACETATE, LEUPROLIDE ACETATE (3 MONTH, 4 MONTH, 6 J1950 MONTH), LUPRON DEPOT J2278 PRIALT, ZICONOTIDE J2323 NATALIZUMAB J2353 OCTREOTIDE ACETATE, SANDOSTATIN LAR DEPOT J2354 OCTREOTIDE ACETATE J2355 NEUMEGA J2357 OMALIZUMAB, XOLAIR J2503 MACUGEN, PEGAPTANIB J2505 NEULASTA J2507 KRYSTEXXA J2778 LUCENTIS, RANIBIZUMAB J2796 NPLATE J2820 LEUKINE, PROKINE J2941 HUMATROPE, NUTROPIN, SOMATROPIN J3262 ACTEMRA J3285 REMODULIN J3489 RECLAST, ZOLEDRONIC ACID, ZOMETA J3490 GENERIC CODE, UNCLASSIFIED DRUGS J3490 OPDIVO 1/9/2015 J3490 TESTOPEL J3490 REPATHA 1/1/2016 J3490 PRALUENT 1/1/2016 J3590 (MOST COMMONLY USED FOR AVASTIN EYE), UNCLASSIFIED BIOLOGICS J7178 HUMAN FIBRINOGEN J7180 FACTOR XIII 7/1/2015 J7181 FACTOR XIII A-SUBUNIT 7/1/2015 J7182 FACTOR VIII - NOVOEIGHT 7/1/2015 J7183 VON WILLEBRAND FACTOR COMPLEX - WILATE 7/1/2015 J7185 FACTOR VIII - XYNTHA 7/1/2015 J7186 VON WILLEBRAND FACTOR COMPLEX -ALPHANATE 7/1/2015

7 HCPCS Code Drug(s) *Effective date J7187 VON WILLEBRAND FACTOR COMPLEX - HUMATE P 7/1/2015 J7189 FACTOR VIIa 7/1/2015 J7190 FACTOR VIII - HEMOFIL M, DOATE DVI, MONOCLATE-P 7/1/2015 J7191 FACTOR VIII (PORCINE) 7/1/2015 J7192 FACTOR VIII - ADVATE, HELIXATE-FS, KOGENATE-FS 7/1/2015 J7193 FACTOR IX - ALPHANINE SD, MONONINE 7/1/2015 J7194 FACTOR IX COMPLEX - BEBULIN VH, PROFILNINE SD 7/1/2015 J7195 FACTOR IX - BENEFIX 7/1/2015 J7198 ANTI-INHIBITOR 7/1/2015 J7199 HEMOPHILIA CLOTTING FACTOR - ELOCTATE 7/1/2015 J7200 FACTOR IX - RIXUBIS 7/1/2015 J7201 J7311 J7311/ C9450 FACTOR IX - FC FUSION PROTIEN (RECOMBINANT) RETISERT, FLUOCINOLONE IMPLANT ILLUVIEN J7312 OZURDEX J7316 JETREA J7321 HYALGAN, SODIUM HYALURONATE (VISCOSUP), SUPARTZ J7323 EUFLEXXA J7324 HYALURONAN, ORTHOVISC J7325 HYALURONIC ACID, HYLAN, SYNVISC, SYNVISC ONE J7326 GEL-ONE J7686 TYVASO, TREPROSTINIL J9010 CAMPATH J9015 PROLEUKIN J9035 AVASTIN J9042 ADCETRIS J9043 JEVTANA J9047 KYPROLIS J9055 ERBITUX J9155 FIRMAGON J9179 HALAVEN J9217 LEUPROLIDE ACETATE (3 MONTH, 4 MONTH, 6 MONTH), LUPRON DEPOT J9218 LEUPROLIDE ACETATE J9228 YERVOY J9262 SYNRIBO 10/15/2015

8 HCPCS Code J9264 J9266 J9301 J9302 J9303 J9305 J9306 J9310 J9351 J9354 J9355 J9400 Q0515 Q2043 Q4074 Drug(s) ABRAXANE ONCASPAR GAZYVA ARZERRA VECTIBIX ALIMTA PERJETA RITUXAN HYCAMTIN KADCYLA HERCEPTIN ZALTRAP GEREF, SERISTIM PROVENGE VENTAVIS *Effective date Q5101 ZARXIO 8/15/2015 Q9979 LEMTRADA *Effective Date = If blank this code required Precert before 1/1/2015 and remains on precert. **Yellow highlight = new precert required in 2016 Precertification requirements document is posted to the Medicare Advantage Provider Portals. i Precertification For the purpose of this document, precertification (aka - prior authorization) indicates a requirement to precertify prior to rendering a service which includes authorization of additional days on concurrent review. Out of network providers may optionally choose to call the health plan to obtain precertification (or a predetermination) regarding whether a service meets benefit and medical necessity criteria.