Updated Information Regarding Online Prior Authorizations for Injectable Outpatient Chemotherapy Services

8/28/2015, Lee Newcomber, MD

April 16, 2015

State Oncology Society Executive Directors

Re: Updated Information Regarding Online Prior Authorizations for Injectable Outpatient Chemotherapy Services

Dear State Society Executives:   

Effective June 1, 2015, UnitedHealthcare will launch a new national online prior authorization program for injectable chemotherapy drugs administrated in an outpatient setting  for a cancer diagnosis to help reduce post service denials for UnitedHealthcare members undergoing treatment in the following plans: 

·         Neighborhood Health Partnership^{1. 2}

·         UnitedHealthcare   – excluding indemnity/Options PPO and select administrative services only (ASO) customers ^{1, 2,}UnitedHealthcare Community Plan – Florida Members Only ¹

·         UnitedHealthcare Life Insurance Company and Golden Rule Insurance Company for select group numbers

The program is designed to expedite the review of treatment compliance with the National Comprehensive Cancer Network (NCCN) Compendium which UnitedHealthcare uses as the clinical source for our chemotherapy coverage decisions because of its reputation as an expert resource for oncologists and its recommendations are transparent to physicians, patients and payers. The new process provides timely approvals for NCCN compliant regimens.    

To support the prior authorization process, we have contracted with CareCore National Oncology Division to review specific regimens and lines of therapy. ³     

The expected advantages to oncologists rendering outpatient chemotherapy include:

·         Ability to see all eligible NCCN-recommended chemotherapy regimens during the authorization process

·         Submission of clinical information during the authorization process for patients who require exceptions due to medical contra-indications 

·         Elimination of  most claim denials after the treatment has been given

Requests for pediatric chemotherapy regimens, rare cancers, or chemotherapy regimens that are not NCCN recommended will receive a timely response if supporting documentation is provided at the time of the prior authorization request.  

The UnitedHealthcare Injectable Chemotherapy Prior Authorization Program includes all injectable chemotherapy drugs used to treat cancer.

·            Chemotherapy injectable drugs (J9000  - J9999), Leucovorin (J0640), Levoleukovorin (J0641)

·            Chemotherapy injectable drugs that have a  Q code are included in the UnitedHealthcare Injectable Chemotherapy Prior Authorization Program

·            Chemotherapy injectable drugs that have not yet received an assigned code and will be billed under a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code require a prior authorization

Prior authorization requests for the following products are NOT part of the UnitedHealthcare Injectable Chemotherapy Prior Authorization Program⁴. 

  ·            Radiotherapeutic agents (i.e., Zevalin and Xofigo)

·            Oral chemotherapy drugs, which are covered under a member’s pharmacy benefit plan

·            Supportive care injectable drugs

·            Use of the chemotherapy drugs for non-cancer diagnosis     

If the member has received injectable chemotherapy drugs in an outpatient setting between March 1, 2015 through May 31, 2015, you do NOT need to request prior authorization until a new chemotherapy drug is administered to the member. We will authorize the chemotherapy regimen the member was receiving prior to May 31, 2015 and the authorization will be effective until May 31, 2016.

If you do not complete the prior authorization process before administering chemotherapy, claims will be denied based on lack of prior authorization. Providers cannot bill members for services that are denied due to lack of prior authorization.  

Receipt of prior authorization does not guarantee or authorize payment. Payment for covered services is contingent upon many factors, including the member's eligibility on the date of service, benefit plan, any claim processing requirements, and the terms of the provider’s participation agreement with UnitedHealthcare.

Information about this program will be available on our physician websiteUnitedHealthcareOnline.com in April and include:  

·         Training videos

·         Live Training Seminar and Live Question and Answer sessions schedule

·         Frequently Asked Questions

·         Link to Oncology Medication Clinical Coverage Policy

·         Case status definitions

·         Cancer Diagnosis Quick Reference Guide

·         Free access to the NCCN compendium

We value our relationship with your society and its members and encourage you to share this information with your membership. For more information, please email us at unitedoncology@uhc.com. Thank you.

Sincerely,

Lee N Newcomer, M.D.
Senior Vice President

^1.  Injectable chemotherapy prior authorizations for Neighborhood Health Partnership, UnitedHealthcare Community Plan – Florida and UnitedHealthcare members receiving chemotherapy in the state of Florida started 5/17/2014

^2.  Some member coverage documents require a primary care physician to initiate a referral to a specialist. Member may also have a specific network service area and network configuration that reflects the needs of targeted population.

^3. UnitedHealthcare will determine coverage decisions for select ASO plan requests for prior authorizations that do not follow the NCCN guidelines.

^4. Member coverage documents and health plan prior authorization requirements may require authorization for these products. Contact the Customer Service phone number on the back of the member’s ID card with any questions. For oral chemotherapy drugs, contact the members Pharmacy Benefit Plan.