PROVIDER NEWSLETTER. Table of Contents. UniCare Health Plan of West Virginia, Inc. June Reimbursement Policy

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1 June 2018 PROVIDER NEWSLETTER UniCare Health Plan of West Virginia, Inc. Table of Contents Provider surveys Page 2 Providing whole person care Page 2 Complex Case Management program Page 3 Use the Provider Maintenance Form to update your information Page 3 Coding Spotlight Pregnancy Page 4 Miscellaneous durable medical equipment billing guidelines Page 5 Claims overpayment recovery update Page 6 How to be compliant with nephropathy required documentation Page 7 Services requiring prior authorization Page 8 Prior authorization requirements Page 9 Medical Policies and Clinical Utilization Management Guidelines update Reimbursement Policy Page 11 Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service Page 14 UWV-NL June 2018

2 Providing whole person care What affects the body affects the mind and vice versa, so good care equals whole person care. Whole person care improves outcomes and satisfaction for patients and providers. The benefits of providing whole person care are so well established that evidence of coordinated care is required by national health care organizations assessing quality of care. UniCare Health Plan of West Virginia, Inc. wants to partner with providers to ensure patients get whole person care and optimum outcomes. Provider surveys Each year, we may reach out to you to ask what we are doing well and how we can continue to improve our services. We use this feedback to continually improve our operations and strengthen our relationship with our providers. Thank you for participating in our network, for providing quality health care to our members and for your timely completion of any surveys you receive. UWV-NL When a primary care provider (PCP) identifies a co-occurring mental health condition, the provider may utilize the Provider Line ( ) for consultation and/or assistance with referrals. Conversely, when a behavioral health specialist recognizes or suspects that a member has a co-occurring physical health need, the provider may also utilize the Provider Line for assistance in coordinating care with the PCP. All health providers have access to a coordination form to alert PCPs that one of their patients has been hospitalized. Providers are encouraged to access and use this form, which can be found on the provider website at One important example of an opportunity to improve health care outcomes is metabolic screening of patients taking antipsychotics. With your help, diabetes and other complications may be prevented. We also hope to see improvements in your satisfaction with respect to communication between physical and mental health providers. We thank you for all you do for your patients/our members and look forward to improved outcomes for them as we focus on enhanced coordination in support of whole person care. UWV-NL Page 2 of 14

3 Complex Case Management program Managing illness can be a daunting task for our members. It is not always easy to understand test results or know how to obtain essential resources for treatment or who to contact with questions and concerns. UniCare Health Plan of West Virginia, Inc. is available to offer assistance in these difficult moments with our Complex Case Management program. Our case managers are part of an interdisciplinary team of clinicians and other resource professionals working to support members, families, primary care physicians and caregivers. The Complex Case Management process utilizes the experience and expertise of the Health Care Management team to educate and empower our members by increasing self-management skills. The Complex Case Management process can help members understand their illnesses and learn about care choices to ensure they have access to quality, efficient health care. Use the Provider Maintenance Form to update your information We continually update our provider directories to ensure that your current practice information is available to our members. At least 30 days prior to making any changes to your practice including updating your address and/or phone number, adding or deleting a physician from your practice, closing your practice to new patients, etc. please notify us by completing the Provider Maintenance Form. Thank you for your help and continued efforts in keeping our records up to date. UWV-NL Members or caregivers can refer themselves or family members by calling the Case Management Referral number at Physicians can refer their patients by contacting us telephonically or through electronic means. We can help with transitions across levels of care so that patients and caregivers are better prepared and informed about health care decisions and goals. You can contact us by phone at Case Management business hours are Monday through Friday from 8 a.m. to 5 p.m. Eastern time. UWV-NL Page 3 of 14

4 Coding Spotlight Pregnancy A provider s guide to diagnose and code for pregnancy Pregnancy demonstrates a woman's amazing creative and nurturing powers while providing for the future. Early and regular prenatal care is vital to the health of the baby and the mother. Pregnancy facts In 2016, 7.2% of women who gave birth smoked cigarettes during pregnancy. Prevalence of smoking during pregnancy was highest for women aged 20 through 24 (10.7%), followed by women aged 15 through 19 (8.5%) and 25 through 29 (8.2%).1 Hypertensive disorders affect up to 10% of pregnancies in the United States.2 Ectopic pregnancy affects 1 to 2% of all pregnancies and is responsible for 9% of pregnancy related deaths in the United States.3 For detailed information on pregnancy coding (risk factors, HEDIS quality measures for prenatal and postpartum care, and ICD 10-CM: general coding and documentation), please view the full pregnancy coding guide on our provider website. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). Resources 1 Cigarette Smoking During Pregnancy: United States, Retrieved from products/databriefs/db305.htm. 2 Hypertension in pregnancy. Retrieved from Task-Force-and-Work-Group-Reports/Hypertension-in-Pregnancy. 3 Barash J.H., Buchanan E.M., Hillson C. Diagnosis and Management of Ectopic Pregnancy. Retrieved from UWV-NL Page 4 of 14

5 Miscellaneous durable medical equipment billing guidelines Reminder: Miscellaneous durable medical equipment (DME) procedure codes (such as E1399) cannot be used as an alternative to specific identified codes. UniCare Health Plan of West Virginia, Inc. (UniCare) will conduct postpayment reviews to ensure the right codes for the right services are used. This applies to all claims for program members. In an effort to improve the provider experience, we continually evaluate coding and billing patterns. Recently, we identified trends related to the use of E1399 DME, miscellaneous. This code is only intended for use when a more appropriate code is not available. When an appropriate code does exist, that code must be used regardless of your contracted rate. It is not appropriate to use E1399 for payment increases. We continue to require prior authorization for the use of miscellaneous code E1399. To request PA, you may use one of the following methods: Web: Fax: Phone: As it is not our policy to inform providers of proper billing processes within prior authorization responses, authorization responses do not include code-specific details. If your service was approved but your claim was denied payment when billed using E1399, the incorrect code was used. You will need to update the authorization and the claim with the appropriate HIPAA-compliant HCPCS code. UniCare will conduct postpayment reviews of code E1399 to ensure proper use. If it is determined a more appropriate code should have been used, we will notify you in writing and advise you of your appeal rights. You can find additional information related to miscellaneous codes in the Unlisted, Unspecified or Miscellaneous Codes reimbursement policy at > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care > Policies, Manuals and Guidelines > Medicaid Reimbursement Policies. UWV-NL Page 5 of 14

6 Claims overpayment recovery update UniCare Health Plan of West Virginia, Inc. (UniCare) appreciates the compassion and dedication with which you care for your patients our members. We know the provision of high-quality and timely health services for UniCare members requires successful collaboration with you, the professionals who care for them. Because timely notifications and detailed information are an important part of successful collaboration, we encourage you to review the following information. We at UniCare truly appreciate your comments regarding recent overpayment recoveries. We need this feedback to improve. We continually audit our claims and payments to ensure we have processed and paid them correctly as this benefits you, your patients and us. When an overpayment is discovered, we initiate the overpayment recovery process by sending written notification to the provider with detailed member information, reason for overpayment, time frames, appeal process and instruction on how to refund the overpayment. All payments should be sent along with a copy of the overpayment letter to: Overpayment Recovery WV P.O. Box Cleveland, OH If you prefer to send overnight, payments should be sent along with a copy of the overpayment letter to: UniCare Health Plan of West Virginia, Inc. Attn: Overpayment Recovery WV Lockbox W. 150th St. Cleveland, OH If you do not contact us to make arrangements for repayment, and payment is not received within 30 days, UniCare will begin recovery from future payments. If multiple overpayment letters are received, you can combine payments and send one check. Please remember to include each of the overpayment letters or an Excel file that includes claim number, member ID number, service dates, recoupment amount, provider name, provider NPI and provider TIN. If you have questions regarding overpayment notification, please contact the UniCare Customer Care Center at Providers may identify an overpayment and proactively submit a refund check to reconcile the overpayment amount. If a provider identifies an overpayment and submits a voluntary refund, a completed Overpayment Refund Notification Form specifying the reason for the return must be included. Submitting an Overpayment Refund Notification Form will allow us to process and reconcile the overpayment in a timely manner. Page 6 of 14

7 Claims overpayment recovery update (cont.) The Overpayment Refund Notification Form can be found on the Provider Resources page of our website: 1. Go to 2. On the top menu bar, under OTHER UNICARE WEBSITES, select Providers. 3. Under Resources for: select State Sponsored Plans. 4. Select West Virginia Medicaid Managed Care. (You will be taken to the Provider Resources page.) 5. Scroll down to Forms and Tools. 6. Select Overpayment Refund Notification Form. UniCare regrets any inconvenience this may cause you; however, we appreciate your cooperation. If you have received this communication in error or need assistance with any other item, please contact our Customer Care Center at UWV-NL How to be compliant with nephropathy required documentation To be compliant with the nephropathy HEDIS submeasure of the Comprehensive Diabetes Care measure, the member must show evidence of angiotensin receptor blockers/angiotensin converting enzyme inhibitors therapy or have undergone a urine test for albumin or protein. Please note that a comprehensive metabolic panel to evaluate kidney function will not meet National Committee for Quality Assurance (NCQA) criteria for compliance for nephropathy. HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA). UWV-NL Page 7 of 14

8 Services requiring prior authorization All programs require prior authorization (PA) for all covered specialty medications, where allowable by state. The scope of this notice will include both professional and facility requests for Medicaid business. Specialty medications that are reported with not otherwise classified (NOC) designation codes and C codes may also require PA before services are provided. Regardless of whether PA is required, all services must be medically necessary to be covered. Even if PA is not required, to avoid a claim denial based on medical necessity, UniCare Health Plan of West Virginia, Inc. (UniCare) encourages providers to review our medical necessity criteria prior to rendering nonemergent services. Medical necessity criteria can be accessed by visiting to view the most current Medical Policies and Clinical Utilization Management Guidelines. If no specific policy is available, the medical necessity review of a drug may be conducted using Medical Policy ADMIN.00006: Review of Services for Benefit Determinations in the Absence of a Company Applicable Medical Policy or Clinical Utilization Management Guideline and/or Clinical Utilization Management Guideline CG-DRUG-01: Off-Label Drug and Approved Orphan Drug Use. Clinical review of specialty medications is in addition to services currently requiring PA. Providers are responsible for verifying eligibility and benefits for UniCare members before providing services. We recommend providers visit to review the list of services and service categories currently requiring PA, with a reminder that the list of services requiring PA will be updated as needed. For clarification regarding whether a specific code or service requires PA, call the number listed below. Except in an emergency, failure to obtain PA may result in denial of reimbursement. Again, please be reminded that the list of services requiring PA will be updated as needed. Providers are strongly encouraged to revisit the Government Business Division Reimbursement Policy Unlisted or Miscellaneous Codes policy, which states NOC codes must be submitted with the correct national drug code (NDC) for proper claim payment. If the required NDC data elements are missing or invalid for the procedure code on a claim line, the claim will be denied. UWV-NL Requesting PA To request PA, report a medical admission or for questions regarding PA, providers may use one of the following methods: Fax: Phone: Page 8 of 14

9 Prior authorization (PA) requirements Drug codes Effective June 1, 2018, PA requirements will change for a number of injectable/implatable drugs. PA requirements will be added to the following: Injection, alglucosidase alfa, (Lumizyme), 10 mg (J0221) Injection, levoleucovorin calcium, 0.5 mg (J06410) Injection, enoxaparin sodium, 10 mg (J1650) Injection, icatibant, 1 mg (J1744) Injection, natalizumab, 1 mg (J2323) Injection, palonosetron HCl, 25 mcg (J2469) Injection, pegloticase, 1 mg (J2507) Injection, asparaginase (Erwinaze), 1,000 IU (J9019) Injection, bendamustine HCl (Treanda), 1 mg (J9033) Injection, degarelix, 1 mg (J9155) Injection, triptorelin pamoate, 3.75 mg (J3315) Injection, degarelix, 1 mg (J9155) Goserelin acetate implant, per 3.6 mg (J9202) Injection, peginesatide, 0.1 mg (for ESRD on dialysis) (J0890) Injection, interferon beta-1a, 30 mcg (J1826) Injection, mitoxantrone HCl, per 5 mg (J9293) UWV-NL Mylotarg (gemtuzumab ozogamicin) Chimeric antigen receptor T-cell therapy Chimeric antigen receptor T-cell (CAR T) therapy, including immunotherapy and all inpatient stays, will continue to require a PA regardless of place of service or if billed with an unlisted code. PA requirements will be added to the following: Tisagenlecleucel (brand name: Kymriah ), up to 250 million CAR-positive viable T-cells, including leukapheresis and dose-preparation procedures, per infusion (Q2040) Axicabtagene Ciloleucel, up to 200 million autologous anti-cd19 CAR T-cells, including leukapheresis and dose-preparation procedures, per infusion (new code effective April 1, 2018) (Q2041) UWV-NL Effective July 1, 2018, PA requirements will change for Mylotarg (gemtuzumab ozogamicin) to be covered by UniCare Health Plan of West Virginia, Inc. through the medical benefit. PA requirements will be added to the following: Mylotarg (gemtuzumab ozogamicin) injection, gemtuzumab ozogamicin, 0.1 mg (J9203) UWV-NL Page 9 of 14

10 PA requirements (cont.) Electrical stimulation devices Effective August 1, 2018, PA requirements will change for electrical stimulation devices. PA requirements will be added to the following: Electrical stimulation device used for cancer treatment, includes all accessories, any type (E0766) UWV-NL Darzalex (daratumumab) Effective August 1, 2018, PA requirements will change for the injectable drug Darzalex (daratumumab) for Medicaid members. PA requirements will be added to the following: Injection, Darzalex (daratumumab), 10 mg (J9145) UWV-NL Cabazitaxel (Jevtana) Effective September 1, 2018, PA requirements will change for the injectable drug Cabazitaxel (Jevtana) to be covered by UniCare Health Plan of West Virginia, Inc. PA requirements will be added to the following: Cabazitaxel (Jevtana) injection, 1 mg (J9043) UWV-NL Federal and state law, as well as state contract language and Centers for Medicare & Medicaid Services guidelines, including definitions and specific contract provisions/ exclusions, take precedence over these PA rules and must be considered first when determining coverage. Noncompliance with new requirements may result in denied claims. To request PA, you may use one of the following methods: Web: Fax: Pharmacy Fax: Phone: Pharmacy Phone: Not all PA requirements are listed here. Detailed PA requirements are available to contracted and noncontracted providers on our provider website ( > Providers > State Sponsored Plan providers > West Virginia - Medicaid Managed Care > Authorization and Preservice Review > Precertification Look UP Tool [PLUTO]). Providers may also call us at or (Pharmacy) for PA requirements. Page 10 of 14

11 Medical Policies and Clinical Utilization Management Guidelines update Medical Policies update On November 8, 2017, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Medical Policies which are applicable to UniCare Health Plan of West Virginia, Inc. (UniCare). These Medical Policies were developed or revised to support clinical coding edits. Several policies were revised to provide clarification only and are not included in the below listing. The Medical Policies were made publicly available on the provider website on the effective date listed below. To search for specific policies, visit Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Publish date Medical Policy number Medical Policy /revised 12/27/2017 DRUG Gemtuzumab Ozogamicin (Mylotarg ) 12/27/2017 DRUG Copanlisib (Aliqopa ) 11/9/2017 MED Axicabtagene ciloleucel (Yescarta ) 11/9/2017 DME Automated Insulin Delivery Devices Revised 12/27/2017 DRUG Eculizumab (Soliris ) Revised 12/27/2017 DRUG Pembrolizumab (Keytruda ) Revised 12/27/2017 DRUG Nivolumab (Opdivo ) Revised 11/9/2017 DRUG Eteplirsen (Exondys 51 ) Revised 12/27/2017 DRUG Durvalumab (Imfinzi ) Revised 12/27/2017 GENE Gene Expression Profiling for Managing Breast Cancer Treatment Revised 11/9/2017 SURG Balloon and Self-Expanding Absorptive Sinus Ostial Dilation Revised Clinical Utilization Management Guidelines update On November 8, 2017, the Medical Policy and Technology Assessment Committee (MPTAC) approved the following Clinical Utilization Management (UM) Guidelines which are applicable to UniCare. These clinical guidelines were developed or revised to support clinical coding edits. Several guidelines were revised to provide clarification only and are not included in the below listing. The Clinical UM Guidelines on this list represent the Clinical UM Guidelines adopted by the Medical Operations Committee for the Government Business Division on January 30, To see the full utilization management guidelines on the website, visit Page 11 of 14

12 Medical Policies and Clinical Utilization Management Guidelines update (cont.) On January 30, 2018, the clinical guidelines were made publicly available on the UniCare Medical Policies and Clinical UM Guidelines subsidiary website. To search for specific guidelines policies, visit Existing precertification requirements have not changed. Please share this notice with other members of your practice and office staff. Update to clinical guideline, CG-MED-39, Central (Hip or Spine) Bone Density Measurement and Screening for Vertebral Fractures Using Dual Energy X-Ray Absorptiometry (CG-MED 39), was published January 30, Effective, January 30, 2018, this clinical guideline will apply to Medicaid lines of business. The clinical indication section specific to female screening of osteoporosis was revised to reflect that an initial (baseline) central (hip or spine) bone density measurement is considered medically necessary when conducted in postmenopausal individuals 65 years of age or older. The guideline also identifies other clinical indications when initial and repeat central bone mineral density measurements are medically necessary. Publish date Clinical UM Guideline number Clinical UM Guideline title /Revised 12/27/2017 CG-DME-40 Electrical Bone Growth Stimulation 12/27/2017 CG-DME-41 Ultraviolet Light Therapy Delivery Devices for Home Use 12/27/2017 CG-DRUG-65 Tumor Necrosis Factor Antagonists 12/27/2017 CG-DRUG-66 Panitumumab (Vectibix ) 12/27/2017 CG-DRUG-68 Bevacizumab (Avastin ) for Non-Ophthalmologic Indications 12/27/2017 CG-DRUG-69 Ustekinumab (Stelara ) 12/27/2017 CG-DRUG-70 Eribulin mesylate (Halaven ) 12/27/2017 CG-DRUG-71 Ziv-aflibercept (Zaltrap ) 12/27/2017 CG-DRUG-72 Pertuzumab (Perjeta ) 12/27/2017 CG-DRUG-73 Denosumab (Prolia, Xgeva ) 12/27/2017 CG-DRUG-74 Canakinumab (Ilaris ) 12/27/2017 CG-DRUG-75 Romiplostim (Nplate ) 12/27/2017 CG-DRUG-77 Radium Ra 223 Dichloride (Xofigo ) 12/27/2017 CG-DRUG-79 Siltuximab (Sylvant ) 12/27/2017 CG-DRUG-80 Cabazitaxel (Jevtana ) Page 12 of 14

13 Medical Policies and Clinical Utilization Management Guidelines update (cont.) Publish date Clinical UM Guideline number Clinical UM Guideline title /Revised 12/27/2017 CG-DRUG-81 Tocilizumab (Actemra ) 12/27/2017 CG-GENE-01 Janus Kinase 2 (JAK2) V617F Gene Mutation Assay 12/27/2017 CG-GENE-02 Analysis of KRAS Status 12/27/2017 CG-GENE-03 BRAF Mutation Analysis 12/27/2017 CG-GENE-04 Molecular Marker Evaluation of Thyroid Nodules 12/27/2017 CG-MED-61 Preoperative Testing for Low Risk Invasive Procedures and Surgeries 12/27/2017 CG-MED-62 Resting Electrocardiogram Screening in Adults 12/27/2017 CG-MED-63 Treatment of Hyperhidrosis 12/27/2017 CG-MED-64 12/27/2017 CG-MED-65 Transcatheter Ablation of Arrhythmogenic Foci in the Pulmonary Veins as a Treatment of Atrial Fibrillation or Atrial Flutter (Radiofrequency and Cryoablation) Manipulation Under Anesthesia of the Spine and Joints other than the Knee 12/27/2017 CG-MED-67 Melanoma Vaccines 12/27/2017 CG-MED-68 Therapeutic Apheresis 12/27/2017 CG-SURG-61 Cryosurgical Ablation of Solid Tumors Outside the Liver 12/27/2017 CG-SURG-62 12/27/2017 CG-SURG-63 Radiofrequency Ablation to Treat Tumors Outside the Liver Cardiac Resynchronization Therapy (CRT) with or without an Implantable Cardioverter Defibrillator (CRT/ICD) for the Treatment of Heart Failure 12/27/2017 CG-SURG-65 Recombinant Human Bone Morphogenetic Protein 12/27/2017 CG-SURG-66 Implanted (Epidural and Subcutaneous) Spinal Cord Stimulators (SCS) 12/27/2017 CG-SURG-67 Treatment of Osteochondral Defects 12/27/2017 CG-SURG-68 Surgical Treatment of Femoracetabular Impingement Syndrome 12/27/2017 CG-DRUG-38 Pemetrexed Disodium (Alimta ) Revised 12/27/2017 CG-DRUG-50 Paclitaxel, protein-bound (Abraxane ) Revised 12/27/2017 CG-DRUG-61 12/27/2017 CG-MED-21 UWVPEC Gonadotropin Releasing Hormone Analogs for the Treatment of Non-Oncologic Indications Anesthesia Services and Moderate ( Conscious ) Sedation Revised Revised Page 13 of 14

14 Reimbursement Policies Policy Update Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service (Policy , effective 09/01/2018) The UniCare Health Plan of West Virginia, Inc. (UniCare) Modifier 25 reimbursement policy provides the criteria for reimbursement for a significant, separately identifiable evaluation and management (E&M) service performed by the same provider on the same day of the original service or procedure. Effective September 1, 2018, UniCare does not allow separate reimbursement for E&Ms performed on the same day as a major surgery (90-day global period). For additional information, refer to the Modifier 25 reimbursement policy at UWV-NL Page 14 of 14