Cardiology Notification Program Frequently Asked Questions

Transcription

1 Cardiology Notification Program Frequently Asked Questions 1. What is the UnitedHealthcare Cardiology Notification Program? The Cardiology Notification Program is a notification protocol required for participating physicians for select inpatient, outpatient, and office-based procedures prior to performance. Administrative reimbursement reduction and individual claim line denial for Current Procedural Terminology (CPT) codes subject to this protocol will apply for non-compliance. This is a prior-notification requirement only. It is not a precertification, preauthorization or a medical necessity determination. It may involve a physician-to-physician discussion, referring to the Cardiology Notification Program Clinical Criteria to help support physicians in their decision-making process. Importantly, please refer to questions 4-8 for more information on the notification process for emergent procedures. 2. When and where does the program become effective? The program became effective for procedures performed on or after the following dates in the states listed: July 1, 2010 in Florida, Missouri, North Carolina, Ohio, and Wisconsin; September 1, 2010 in Alabama, Arkansas, Arizona, Delaware, Georgia, Hawaii*, parts of Illinois, Indiana, Kansas, Louisiana, Massachusetts, Maine, Michigan, Mississippi, Nevada, New Hampshire, New Mexico, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Vermont and West Virginia; October 1, 2010 in Colorado and Kentucky; December 1, 2010 in California, Maryland, Rhode Island*, and Washington DC. Effective February 1, 2012 (Medicare Advantage Members only), the program will be expanded to include physicians who practice in the state of Iowa (except Western Iowa) and the parts of Illinois where the program is not already effective. Effective June 16, 2012 (for UnitedHealthcare Choice, Choice Plus, Select, Select Plus, and Deere Premier benefit plans), the program will be expanded to include physicians who practice in the state of Iowa (except Western Iowa) and the parts of Illinois where the program is not already effective. A full schedule of effective dates by state is available at UnitedHealthcareOnline.com > Clinician Resources >Cardiology > Cardiology Notification Program. * Medicare Specific: In Hawaii and Rhode Island, notification will be required only for Medicare Advantage members enrolled in benefit plans issued or administered by United Healthcare Medicare Complete, United Healthcare Dual Complete, United Healthcare Chronic Complete, and AARP Medicare Complete. This program does not apply to UnitedHealthcare commercial membership in these states. 3. How do I submit Cardiology Notification? Cardiology Notification can be submitted online at UnitedHealthcareOnline.com (select Notifications > Cardiology Notification Submission & Status), by calling toll-free at or by faxing

2 4. Is UnitedHealthcare using a vendor to administer this program? Yes. CareCore National s Cardiology Division will administer this notification program for UnitedHealthcare. We have taken special steps to ensure that the clinical criteria we are using are current with best practices and have sought guidance from our external cardiac Scientific Advisory Board (which is comprised of leading clinical and academic board-certified cardiologists) in reviewing the clinical criteria and decision algorithms. These clinical criteria will be transparent and subject to ongoing review by these expert cardiologists. For your reference, the clinical criteria can be found online at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification Program. 5. What if a diagnostic catheterization or electrophysiology implant is needed on an emergent basis? Physicians should not delay emergency care in order to notify. If a physician determines that a diagnostic catheterization or electrophysiology implant is required on an emergent basis, the service should be performed, and notification should be requested retrospectively. 6. What is the Retrospective Notification Process? Retrospective Notification is only allowed in two situations: (1) when a service subject to the notification requirement is required on an emergent basis; and (2) when a service subject to the notification requirement is performed during the course of an inpatient stay. In these situations, the service may be performed, and notification can be provided retrospectively. Retrospective Notification requests must be made within 30 calendar days of the service. Rendering physicians should follow the same notification process outlined for a standard request. Documentation must include an explanation as to why the procedure was required on an emergent basis or that it was performed during the course of an inpatient stay. Retrospective Notification is not available for outpatient elective procedures. If a claim is submitted prior to the Retrospective Notification Process being completed, it will receive an automated denial for lack of notification; however, the claim will be automatically reprocessed if Retrospective Notification is received within 30 calendar days of the date of service, and the procedure meets the criteria for an emergent procedure or was performed during an inpatient stay. 7. When did the Retrospective Notification timeframe change from 14 to 30 calendar days? Due to provider feedback, on November 1, 2011, the timeframe to submit Retrospective Notification for emergent procedures or procedures performed during the course of an inpatient stay was extended from 14 to 30 calendar days. 8. What if a diagnostic catheterization or electrophysiology implant procedure is needed on an urgent basis? Physicians may request a notification number on an urgent basis if the physician determines that it is medically required that the procedure be performed on an urgent basis. A notification number will be issued for urgent requests within three (3) hours after UnitedHealthcare (through CareCore) receives all required information. If the physician determines that care must be provided before a notification number can be issued on an urgent basis, the services should be performed and notification should be requested retrospectively following the Retrospective Notification Process. 9. Is the Retrospective Notification Process available for cases where the diagnostic catheterization or electrophysiology implant is done during the course of an inpatient admission but is not the reason for the admission? Yes. In order to ensure that patient care is not delayed while in the inpatient setting, the Retrospective Notification Process is available for procedures performed during the course of an inpatient admission. For example, if a patient is admitted for a reason other than the procedures subject to this program (e.g., heart failure) and it is determined during a cardiac consult that a

3 diagnostic catheterization or electrophysiology implant is required, then the physician should proceed with the procedure and submit the notification on a retrospective basis within 30 calendar days of the date of service. This Retrospective Notification Process does not apply to the facility s separate Admission Notification requirement. 10. Will I receive more than one Provider Remittance Advice (PRA) when submitting a Retrospective Notification? As stated above, if a claim is submitted prior to the Retrospective Notification Process being completed, it will receive an automated denial for lack of notification; however, the claim will automatically be reprocessed if Retrospective Notification is received within 30 calendar days of the date of service. Due to this process, the physician will receive two PRAs: the initial PRA showing a claim denial for lack of notification, and an additional PRA reflecting payment for the service for which a Retrospective Notification was received. 11. What if the physician is not given sufficient information from the member to provide Retrospective Notification within 30 calendar days of the service? If the physician learns that notification is required, and the 30-day Retrospective Notification period has expired, the physician will not be held responsible for lack of notification if the physician provides sufficient documentation that the denied claim should be overturned. The standard appeals process will apply. Acceptable documentation to overturn the denied claim may include: member presented the wrong insurance card, member did not present any insurance card (member presented as self-pay), member was admitted through the ER and was unable to provide an insurance card, or hospital admission sheet (original/oldest) does not show Deere Premier, UnitedHealthcare Medicare Complete, UnitedHealthcare Dual Complete, UnitedHealthcare Chronic Complete or AARP Medicare Complete as the primary plan (see question 39). 12. For which products is Cardiology Notification required? This program applies to members enrolled in Deere Premier (effective June 16, 2012), UnitedHealthcare Choice, Choice Plus, Select and Select Plus benefit plans as well as Medicare Advantage members enrolled in benefit plans issued or administered by UnitedHealthcare Medicare Complete, UnitedHealthcare Dual Complete, UnitedHealthcare Chronic Complete and AARP Medicare Complete for providers who are subject to the UnitedHealthcare Administrative Guide. This program does not apply to plans jointly offered by UnitedHealthcare and Harvard Pilgrim Health Care for members using the Harvard Pilgrim provider network. The program does not apply to members enrolled in Medicaid government plans such as AmeriChoice, or benefit plans issued or administered by any legal entities associated with any of the following affiliates: Oxford Health Plans, UnitedHealthcare West, MD Individual Practice Association, Inc. (M.D. IPA), Optimum Choice, Inc., MAMSI Life and Health Insurance, Neighborhood Health Partnership*, River Valley**, or Sierra. Members of these plans are subject to the administrative guide, manual or supplement of that Affiliate. The existing requirements regarding prior notification, preauthorization and/ or precertification for the above listed excluded entities remain in place and the process for authorization will not change. * Please refer to for details around the Cardiology Precertification Program effective December 1, 2011 for NHP members. ** Please refer to for details around the Cardiology Preauthorization Program effective June 16, 2012 for River Valley members. 13. Are patients with Indemnity and PPO plans out-of-scope for this program? Yes. Managed Indemnity, PPO, and Options PPO plans are out-of scope for the Cardiology Notification Program. The plans that are inscope are listed on the Product Comparison Grid available online at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification Program > Additional Information.

4 14. What cardiac modalities will require notification under this program? The following CPT codes will require notification under this program: Diagnostic left heart catheterization (ventriculography only): CPT code Combined right and left heart catheterization (ventriculography only): CPT code Coronary Arteriogram (no ventriculography): CPT codes 93454, Coronary Arteriogram and right catheterization (no ventriculography): CPT codes 93456, Coronary Arteriogram (with ventriculography): CPT codes 93458, Coronary Arteriogram and right catheterization (with ventriculography: CPT codes 93460, Electrophysiology Implants: CPT codes 33206, 33207, 33208, 33212, 33213, 33214, 33225, 33240, Importantly, the following Electrophysiology Implant CPT codes will be effective January 1, 2012 and notification will be required for these procedures for dates of service on or after January 1, 2012: 33221, 33224, 33227, 33228, 33229, 33230, 33231, 33262, and Can the CPT code be modified on a cardiac notification? Under the CPT Code Crosswalk Table, for certain specified CPT code combinations, physicians and other health care professionals will not be required to contact UnitedHealthcare (through CareCore) to modify the existing notification record. A complete listing of codes is available at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification Program. However, for code combinations not listed on the CPT Code Crosswalk Table, the Cardiology Notification Protocol provision for additional services will still apply and a modification to the notified procedure would need to occur. 16. What is the CPT Code Crosswalk Table? The CPT Code Crosswalk Table includes a mapping of CPT codes that are interchangeable for notification. For example, if a physician calls to notify for a left heart catheterization and provides the CPT code and ultimately bills a 93453, the code substitution is appropriate if these codes are mapped as interchangeable on the Crosswalk Table. Code substitutions are not appropriate, however, if the codes are not mapped as interchangeable on the Crosswalk table. For example, if a physician calls to notify for a pacemaker insertion (33206) and instead implants a defibrillator (33240) and these codes are not mapped as interchangeable on the Crosswalk Table, then this substitution is inappropriate. An administrative reimbursement reduction would be applied unless the physician called to notify of the change in the procedure prior to rendering the procedure. 17. In what places of service is a cardiac notification required? Notification under the Cardiology Notification Program is required for services rendered in all settings including, but not limited to, inpatient, outpatient, office-based and emergency department. 18. Are facility claims subject to administrative reimbursement reduction for noncompliance with the cardiology notification process? No. Facility claims will not be denied for noncompliance with the cardiology notification process at this time. Only physician claims submitted for cardiac diagnostic catheterization or electrophysiology implant procedures are subject to the cardiology notification requirement and will be subject to administrative reimbursement reduction for non-compliance with the cardiology notification process. As a reminder, the standard admission notification requirement imposed on facilities for all inpatient admissions does not exempt a physician from the Cardiology Notification Program requirement. Separate Cardiology Notification is required when

5 these cardiac procedures are performed in the inpatient setting or emergency department. The Retrospective Notification Process should be followed to provide notification for procedures performed during the course of an inpatient stay or on an emergent basis within 30 calendar days of the date of service. 19. How do I know if a cardiac notification is required for a UnitedHealthcare member? If the UnitedHealthcare member is enrolled in Deere Premier (effective June 16, 2012) or a Choice, Select or Medicare Advantage benefit plan, in most instances, notification is required. If the member s health care identification (ID) card does not distinguish if coverage is Deere Premier, or a Choice, Select or Medicare Advantage product, notification requirements can be verified by initiating the notification online or by phone , and providing the member s demographic information. The system will enable you to continue with the notification process or respond automatically that notification is not needed. 20. Is notification required for pediatric cases? Yes. However, the process for pediatric cases is abbreviated. Once the patient s age is entered during the notification process, a notification number will be given immediately if the age is less than twenty-one (21) years. 21. Who is responsible for providing notification of a cardiac procedure? A. Rendering physicians or their designee are responsible for providing notification. Designees may be a member of the physician s office staff or the facility if they have the relevant clinical information to notify for the procedure. However, if a physician-to-physician dialogue is requested, then the rendering physician must participate in that conversation. 22. Who is authorized to conduct a physicianto-physician dialogue for the rendering physician? Covering physicians, physician s assistants or nurse practitioners may engage in the physicianto-physician dialogue on behalf of the rendering physician if the rendering physician will be unavailable for more than three business days. 23. What is the process to submit additional clinical information to support the physician-to-physician dialogue? If you are required to engage in a physician-tophysician dialogue after initiating the notification process, you may submit additional clinical information by calling toll-free and selecting option five (customer care professional), then select option five (cardiac catheterization and cardiac pacemaker implants), then select option three (speak with a customer service representative). 24. What if I m having trouble submitting notification on UnitedHealthcareOnline.com? If you need assistance with your UnitedHealthcareOnline.com User ID or Password, call our Help Desk toll free, at UHCFAST ( ). 25. Are there any physician exclusions from the Cardiology Notification Program? No. There are no exclusions from the Cardiology Notification Program. All physicians regardless of their UnitedHealth Premium quality and cost efficiency designation are required to provide notification for each diagnostic catheterization imaging study and electrophysiology implant. 26. Do I need a notification number for each procedure I order? Yes. A notification number is required for each CPT code and each notification number is CPT code-specific. Notification numbers are not required to be submitted on the claim form as UnitedHealthcare matches claims and the associated notifications, automatically. 27. What information will be required on the cardiac notifications? Member information such as the UnitedHealthcare ID number, name, address, telephone number, group number and date of

6 birth may be required. UnitedHealthcare may also require the name of the rendering physician his or her tax identification number (TIN), specialty, address, and telephone number as well as the contact person at the rendering physician s office. In addition, clinical information may be required, including but not limited to, the procedure(s) being requested, with the CPT code(s), the diagnosis or rule out with the ICD-9-CM (or its successor) code(s), the member s clinical condition, which may include any symptoms, treatments, dosage and duration of drugs, and dates for other therapies, dates (and results) of prior imaging studies performed, and any other information the rendering physician believes would be useful in evaluating whether the service ordered meets clinical criteria. To ensure physicians or physician representatives have the required information available to initiate the notification process, the specific information required for notification submissions will be listed in detail and posted to UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification Program. 28. When will the notification number be provided to the rendering physician? If the procedure is consistent with clinical criteria a notification number will be provided to the physician upon submission. The rendering physician always maintains final decision authority for the performance of the procedure, but, if we believe the procedure is not consistent with clinical criteria, a cardiologist or electrophysiological physician will conduct a peer-to-peer discussion with the rendering physician. A notification number will be provided following this conversation. Without completion of the entire notification process, a notification number will not be issued and may result in an administrative reimbursement reduction or any action available under the terms of the rendering physician s participation agreement. 29. How can I ensure that a notification has been submitted for a cardiac procedure? The rendering physician may confirm that a notification is on file by going online at UnitedHealthcareOnline.com (select Notifications > Cardiology Notification Submission & Status) or by contacting UnitedHealthcare toll-free at What should I do if I determine there is no notification on file for a patient scheduled for a cardiac procedure? If the rendering physician determines there is no notification on file, they should submit a notification online at UnitedHealthcareOnline.com (select Notifications > Cardiology Notification Submission & Status), by calling UnitedHealthcare toll-free at , or by faxing What is the difference between a case number, a Commercial notification number, and a Medicare Advantage notification number? A case number is a 10-digit numeric value assigned for every Cardiology Notification case, for example, A case number is used for reference purposes during the peer-topeer discussion only. Case numbers are not valid for claim payment. A Commercial notification number contains the letters CC followed by an 8-digit numeric value and the CPT code, for example, CC A notification number will be given immediately for every Commercial procedure that is consistent with the clinical criteria. A Medicare Advantage notification number contains the letter A followed by a 9-digit numeric value, for example, A A Medicare Advantage notification number will be given for every Medicare procedure that is consistent with the clinical criteria. 32. When will a physician-to-physician dialogue be required for a cardiac procedure? If the cardiac procedure requested is not consistent with clinical criteria, the rendering physician will be required to engage in a physician-to-physician dialogue. The rendering physician will be informed

7 why the requested procedure failed to meet the clinical criteria and will be given the chance to discuss with a peer cardiologist any additional information supporting his or her clinical decision. 33. What happens during the physicianto-physician discussion if there is disagreement with the recommendation on whether a procedure should be performed or the most appropriate procedure to perform? Will a notification number still be issued for the requested procedure? Yes. Upon completion of the discussion, the rendering physician will confirm the procedure ordered and a notification number will be issued. The rendering physician maintains the final decision authority for the performance of the procedure. 34. How long will I have to conduct the physician-to-physician dialogue for a cardiac procedure that is found inconsistent with clinical criteria? The rendering physician has three business days to engage in the dialogue before the request expires. Physician-to-physician discussions can be initiated by calling and selecting option four (engage in a physician-to-physician discussion) and then option two (cardiac catheterization and cardiac pacemaker implants). 35. What happens if I do not complete the physician-to-physician dialogue within the three business day timeframe? The notification will expire and the corresponding claim will be denied as if a notification was not received. 36. How long is a notification number valid? Except where the notification number expires because the physician-to-physician dialogue did not occur within three (3) business days, notification numbers are valid for forty-five calendar days. When a notification is entered for a procedure, UnitedHealthcare will use the day notification was issued as the starting point for the 45-day period in which the examination or procedure must be completed. If the examination or procedure is not completed within 45 calendar days, a new Notification number must be obtained; that is, the rendering physician must go through the notification process again. 37. What is the consequence for failure to provide notification? Compliance with this notification protocol is required. A notification number will not be issued and an administrative reimbursement reduction and individual claim line denial for CPT codes subject to this protocol will apply to the rendering physician if the entire notification process (including a physician-to-physician discussion in some cases) is not completed. 38. If my claim is denied for lack of notification, can I balance bill the patient? No. Balance billing the patient is precluded under the Cardiology Notification Program as outlined in the Cardiology Notification Protocol and per the physician s participation agreement. 39. Is the notification number required on the claim form to ensure payment? There is no need to put the notification number on the claim form; however, the physicians may do so, at their discretion. 40. How will I be notified if a claim for a cardiac procedure has been denied for lack of notification? The remark code CD will be used to indicate administrative reimbursement reduction for lack of notification on the physician remittance advice. The CD remark code states: According to the terms of the provider s participation agreement and our protocols, notification for services was required but was not received. Therefore, the applicable reimbursement reduction has been applied and deducted from the provider s payment. According to the participation agreement, the patient may not be billed for the amount of the reimbursement reduction. However, the patient is responsible for the coverage plan copay, deductible or coinsurance amounts.

8 41. If Deere Premier, UnitedHealthcare Medicare Complete, UnitedHealthcare Dual Complete, UnitedHealthcare Chronic Complete, or AARP Medicare Complete is the secondary plan, is notification required on cardiac procedures? No. Notification is not required when Deere Premier, UnitedHealthcare Medicare Complete, UnitedHealthcare Dual Complete, UnitedHealthcare Chronic Complete or AARP Medicare Complete is secondary to any other plan. 42. Does receipt of a notification number guarantee that UnitedHealthcare will pay the claim? No; receipt of a notification number does not guarantee or authorize payment, but simply is confirmation that notification was made. Medical coverage and payment authorization is a separate process determined by other factors including the member s benefit plan documents and the physician participation agreement with UnitedHealthcare. 43. Where can I reference the protocol and clinical criteria supporting this program? For your reference, the clinical criteria and the Cardiology Notification Protocol can be found online at UnitedHealthcareOnline.com > Clinician Resources > Cardiology > Cardiology Notification Program. 44. Whom can I contact to get more information about the Cardiology Notification Program? For further information about the Cardiology Notification Program, please contact your local UnitedHealthcare Market Medical Director or Network Management representative. 45. Will UnitedHealthcare provide reporting to physician groups on the clinical data gathered from this program? UnitedHealthcare will make group-specific reports available on an ad hoc basis as requested by groups. 46. Will UnitedHealthcare incorporate the American College of Cardiology (ACC) Appropriate Use Criteria for diagnostic catheterizations into its clinical criteria? Once the ACC publishes appropriate use criteria for diagnostic catheterizations we will incorporate them into our clinical criteria. In addition, once the ACC appropriate use criteria are incorporated and we have enough experience and clinical data collected from this program, we will analyze which physician groups are consistently ordering appropriate tests and will consider a goldcarding process for those groups to expedite the notification requirement. M48776-F 5/ United HealthCare Services, Inc.