Re: Important Benefit Changes for UnitedHealthcare Community Plan Members Effective October 1, 2013

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1 8 Cadillac Drive, Suite 100 Brentwood, TN [Date] «Physician/Group Name» «Contact Name» «Address» «City», «State» «Zip» Re: Important Benefit Changes for UnitedHealthcare Community Plan Members Effective October 1, 2013 Dear [Provider Name]: As part of its 2014 budget, the Tennessee Legislature enacted several reimbursement and member benefit changes as detailed in the attached memo from the Bureau of TennCare. This letter explains the changes that take effect Oct. 1, We will send you a separate letter explaining the changes that were effective July 1 if they apply to you. For claims with dates of service on or after Oct. 1, 2013, UnitedHealthcare Community Plan will make changes to the following member benefits: Facet/Medial Branch Block Injections Trigger Point Injections Epidural Steroid Injections Urine Drug Screens TENS Unit for Chronic Lower Back Pain (CLBP) Facet/Medial Branch Block Injections: Therapeutic Facet/Medial Branch Block Injections are not covered. Diagnostic Facet/Medial Branch Block Injections will have a limit of four per calendar year applied to CPT codes 64490, 64491, 64492, 64493, and Facet/Medial Branch Block Injections must be performed by a physician/practitioner as required by T.C.A (attached). Medical records are required when submitting a claim with CPT codes 64490, 64491, 64492, 64493, and Trigger Point Injections: Benefit limits will be applied to CPT codes and These CPT codes will have a limit of four per muscle group in any period of six consecutive months. Counting will start with the first shot on or after Oct. 1, UHC2095b_

2 Epidural Steroid Injections: Benefit limits will be applied to CPT codes 62310, 62311, 62318, 62319, 64479, 64480, and These CPT codes will have a limit of three in any period of six consecutive months. Counting will start with the first shot on or after Oct. 1, Urine Drug Screens: Benefit limits will be applied to CPT codes G0434 and G0431. CPT code G0434 will apply a limit of 12 per calendar year and G0431will apply a limit of four per calendar year. Limits do not apply in the emergency department. We will no longer cover Urine Drug Screens under the 8xxxx series CPT codes. TENS Unit Applications: CPT E0720, E0730, E0731, A4557 and A4595 will not be covered for CLBP. This includes multiple specific diagnoses for the symptoms of CLBP. If you have any questions, please call between 7a.m. and 5p.m. (CST). You may also review these benefits at UHCCommunityPlan.com > For Health Care Professionals >Select Your State > Claims and Member Information. Thank you. Sincerely, /s/ Darren Hodgdon Chief Operating Officer UHC2095b_

3 STATE OF TENNESSEE DEPARTMENT OF FINANCE AND ADMINISTRATION DIVISION OF HEALTH CARE FINANCE AND ADMINISTRATION BUREAU OF TENNCARE 310 GREAT CIRCLE ROAD NASHVILLE, TENNESSEE MEMORANDUM DATE: September 27, 2013 TO: FROM: TennCare Managed Care Organizations Keith Gaither, Director of Managed Care Operations SUBJECT: Budget Reduction s Effective July 1, 2013 and October 1, 2013 This memo serves to outline each of the budget reduction items that were included in the 2014 Budget that was passed by the General Assembly. All items have been previously discussed and provided in writing to your organization; however, this document incorporates both the items that were to be implemented effective July 1, 2013 and items that must be implemented October 1, I. Budget Reductions Effective July 1, 2013 a. Cesarean and Vaginal Delivery Reimbursement Cesarean and Vaginal Delivery Reimbursement Effective July 1, 2011 Effective July 1, 2012 Effective July 1, 2013 Cesarean and vaginal deliveries will be reimbursed at the same rate effective July 1, MCOs are directed to increase their vaginal delivery rates by 17%. Additionally, MCOs are to pay the vaginal delivery rate for corresponding C-Section deliveries. Cesarean and vaginal deliveries are reimbursed at the same rate. MCOs pay the current vaginal delivery rate for corresponding C-Section deliveries. MCOs are directed to decrease their vaginal and corresponding C-Section delivery rate by 7% points effective July 1, This should result in an effective 10% increase from the rates paid before July 1, Cesarean and vaginal deliveries are reimbursed at the same rate. MCOs pay the current vaginal delivery rate for corresponding C-Section deliveries. MCOs are directed to decrease their vaginal and corresponding C-Section delivery rate by 5% points effective July 1, This should result in an effective 5% increase from the rates paid before July 1, 2011.

4 Budget Memorandum to MCOs September 27, 2013 Page 2 Vaginal to Cesarean CPT Crosswalk Description Vaginal CPT Code Cesarean CPT Code Global OB Care Delivery Only Delivery and Postpartum VBAC N/A VBAC Delivery Only VBAC Delivery and Postpartum Routine OB Care Vaginal to Cesarean DRG Crosswalk Vaginal Code Description 774 Vaginal Delivery w Complicating Diagnosis 775 Vaginal Delivery w/o Complicating Diagnosis Corresponding Cesarean Code Description 765 Cesarean with CC/MCC 766 Cesarean w/o CC/MCC b. DME/Back Brace Reimbursement BACK BRACE REIMBURSEMENT HCPC Code L0637 $ L0631 $ L0627 $ Maximum Allowed Amount c. Implementation of Medicare standards for coverage of TENS and CLBP Effective for claims with dates of service on or after June 8, 2012, CMS believes the evidence is inadequate to support coverage of TENS for CLBP as reasonable and necessary. Thus, effective for claims with dates of service on and after June 8, 2012, Medicare will not allow coverage of TENS for CLBP. TennCare has adopted this policy as well. MCOs are expected to implement these guidelines for dates of service July 1, 2013 and thereafter.

5 Budget Memorandum to MCOs September 27, 2013 Page 3 II. Budget Reductions Effective October 1, 2013 for Adults Description Codes Policy Comments Facet/Medial Branch Block Injections Trigger Point Injections Epidural Steroid Injections Urine Drug Screens G0434 G0431 Limit of 4 Diagnostic Medial Branch Block Injections per Calendar Year Therapeutic Facet/Medial Branch Block Injections Not Covered Must be performed by a physician/practitioner as required by State law (Public Chapter No. 961/SB No pdf Limit of 4 per muscle group in any period of 6 consecutive months (counting will start with the first shot on or after October 1) Limit of 3 in any period of 6 consecutive months (counting will start with the first shot on or after October 1) G Limit of 12 per calendar year G Limit of 4 per calendar year Limits do not apply in the emergency department (Note: this includes urine drug screens that are sent to an independent lab on the same date of service for the same enrollee on the same day of an emergency department visit.) MCO to define supporting documentation that shall be required to accompany a claim in order to be processed. The supporting documentation must demonstrate that the service and provider qualify for payment. 271U will report number of Diagnostic Medical Branch Block Injections paid and apply encounter edits if exceeded Post Medical Necessity Review 271U will report number of injections paid for MCO informational purposes to prompt Medical Necessity Review but TennCare will not apply edits Limits will not apply in conjunction with Labor and Delivery (codes for L&D should be different) 271U will report number of injections paid and apply encounter edits if exceeded Adhere to Medicare Guidelines for billing Urine Drug Screens. Do Not Cover Urine Drug Screens Under 8xxxx series CPT codes Each G code carries its own limit: G0434 = limited to 12 units per member, per calendar year G0431 = limited to 4 units per member in addition to the 12 for G0434 and may be billed on the same date of service 271U will report number of urine drug screens paid and apply encounter edits if exceeded

6 Budget Memorandum to MCOs September 27, 2013 Page 4 Description Codes Policy Comments TENS Units E0730 Non-Covered for Chronic Low Back Pain (NOTE: This includes multiple specific diagnoses for the symptom of chronic low back pain) Prior Auth Or Post Medical Necessity Review Note: 1) Please remember with Benefit Limits, you must provide a Notice of Limit (EOB) to members once a service is billed that exceeds a limit. 2) If a service is requested after a limit is exceeded, a Grier notice of denial must be sent.

7 of Z!Cennessee ~tate PUBLIC CHAPTER NO. 961 SENATE BILL NO By McNally Substituted for: House Bill No By Hensley, Shaw AN ACT to amend Tennessee Code Annotated, Title 63, relative to interventional pain management. BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF TENNESSEE: SECTION 1. Tennessee Code Annotated, Section , is amended by adding a new subsection (f) as follows: (f) An advanced practice nurse shall only perform invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under Title 68, Chapter 11 under the direct supervision of a Tennessee physician licensed pursuant to Chapter 6 or 9 of this title who is actively practicing spinal injections and has current privileges to do so at a facility licensed pursuant to Title 68, Chapter 11. The direct supervision provided by a physician in this subsection (f) shall only be offered by a physician who meets the qualifications established in (a)(1) or (a)(3) or (a)(1) or (a)(3). For purposes of this subsection (f), direct supervision is defined as being physically present in the same building as the advanced practice nurse at the time the invasive procedure is performed. This subsection (f) shall not apply to an advanced practice nurse performing major joint injections except sacroiliac injections, or to performing soft tissue injections or epidurals for surgical anesthesia or labor analgesia in unlicensed settings. SECTION 2. Tennessee Code Annotated, Section (e), is amended by deleting the language "Nothing" at the beginning of the subsection and substituting instead the following: With the exception of subsection (f), nothing SECTION 3. Tennessee Code Annotated, Section , is amended by adding a new subdivision (5) as follows: (5) A physician assistant shall only perform invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under Title 68, Chapter 11 under the direct supervision of a Tennessee physician licensed pursuant to Chapter 6 or 9 of this title who is actively practicing spinal injections and has current privileges to do so at a facility licensed pursuant to Title 68, Chapter 11. The direct supervision provided by a physician in this subsection shall only be offered by a physician who meets the qualifications established in (a)(1) or (a)(3) or (a)(1) or (a)(3). For purposes of this subdivision (5), direct supervision is defined as being physically present in the same building as the physician assistant at the time the invasive procedure is performed. This subdivision (5) shall not apply to a physician assistant performing major joint injections except sacroiliac injections, or to performing soft tissue injections or epidurals for surgical anesthesia or labor analgesia in unlicensed settings. SECTION 4. Tennessee Code Annotated, Title 63, Chapter 6, Part 2, is amended by adding a new section as follows: (a) A physician licensed pursuant to this chapter may only practice interventional pain management if the licensee is either: ( 1) Board certified through the American Board of Medical Specialties (ABMS) or the American Board of Physician Specialties (ABPS)/American

8 SB 1935 Association of Physician Specialists (AAPS) in one of the following medical specialties: (A) Anesthesiology; (B) Neurological surgery; (C) Orthopedic surgery; (D) Physical medicine and rehabilitation; (E) Radiology; or (F) Any other board certified physician who has completed an ABMS subspecialty board in pain medicine or completed an ACGMEaccredited pain fellowship; (2) A recent graduate in a medical specialty listed in (a)(1) not yet eligible to apply for ABMS or ABPS/AAPS board certification; provided, there is a practice relationship with a physician who meets the requirements of subdivision (a)(1) or an osteopathic physician who meets the requirements of (a)(1); (3) A licensee who is not board certified in one of the specialties listed in subdivision (a)(1) but is board certified in a different ABMS or ABPS/AAPS specialty and has completed a post-graduate training program in interventional pain management approved by the board; (4) A licensee who serves as a clinical instructor in pain medicine at an accredited Tennessee medical training program; or (5) A licensee who has an active pain management practice in a clinic accredited in outpatient interdisciplinary pain rehabilitation by the Commission on Accreditation of Rehabilitation Facilities or any successor organization. (b) For purposes of this section, interventional pain management is the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under Title 68, Chapter 11. (c) The board is authorized to define through rulemaking the scope and length of the practice relationship established in subdivision (a)(2). (d) A physician who provides direct supervision of an advanced practice nurse or a physician's assistant pursuant to or must meet the requirements set forth in subdivision (a)(1) or (a)(3). (e) A physician who violates this section is subject to disciplinary action by the board pursuant to , including, but not limited to, civil penalties of up to one thousand dollars ($1,000) for every day this section is violated. SECTION 5. Tennessee Code Annotated, Title 63, Chapter 9, Part 1, is amended by adding a new section as follows: (a) A physician licensed in this chapter may only practice interventional pain management if the licensee is either: (1) Board certified through the American Osteopathic Association (AOA) or the American Board of Physician Specialties (ABPS)/American Association of Physician Specialists (AAPS) in one of the following medical specialties: (A) Anesthesiology; (B) Neuromusculoskeletal medicine; (C) Orthopedic surgery; 2

9 SB 1935 (D) Physical medicine and rehabilitation; (E) Radiology; or (F) Any other board certified physician who has completed an ABMS subspecialty board in pain medicine or completed an ACGMEaccredited pain fellowship; (2) A recent graduate of a medical specialty listed in subdivision (a)(1) not yet eligible to apply for AOA or ABPS/AAPS specialty certification; provided, there is a practice relationship with an osteopathic physician who meets the requirements of subdivision (a)(1) or a physician who meets the requirements of (a)( 1 ); (3) A licensee who is not board certified in one of the specialties listed in subdivision (a)(1) but is board certified in a different AOA or ABPS/AAPS specialty and has completed a post-graduate training program in interventional pain management approved by the board; (4) A licensee who serves as a clinical instructor in pain medicine at an accredited Tennessee medical training program; or (5) A licensee who has an active pain management practice in a clinic accredited in outpatient interdisciplinary pain rehabilitation by the Commission on Accreditation of Rehabilitation Facilities or any successor organization. (b) For purposes of this section, interventional pain management is the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine or block of major peripheral nerves of the spine in any setting not licensed under Title 68, Chapter 11. (c) The board is authorized to define through rulemaking the scope and length of the practice relationship established in subdivision (a)(2). (d) An osteopathic physician who provides direct supervision of an advanced practice nurse or a physician's assistant pursuant to or must meet the requirements set forth in subdivision (a)(1) or (a)(3). (e) An osteopathic physician who violates this section is subject to disciplinary action by the board pursuant to , including, but not limited to, civil penalties of up to one thousand dollars ($1,000) for every day this section is violated. SECTION 6. This act shall take effect July 1, 2013, the public welfare requiring it. 3

10 SENATE BILL NO PASSED: April 27, 2012 BETH HARWELL, SPEAKER HOUSE OF REPRESENTATIVES BILL HASLAM, GOVERNOR