Prior Authorization for Outpatient Injectable Chemotherapy Frequently Asked Questions

Transcription

1 Prior Authorization for Outpatient Injectable Chemotherapy Frequently Asked Questions Key Points We require prior authorization for injectable chemotherapy given in an outpatient setting to a member who is being treated for cancer, regardless of age. This policy affects UnitedHealthcare commercial, UnitedHealthcare Oxford 1 and UnitedHealthcare Community Plan members. This requirement supports the Triple Aim to improve care experiences, outcomes and the total cost of care for our members. Overview We require prior authorization for injectable chemotherapy given in an outpatient setting. This requirement supports the Triple Aim to improve care experiences, outcomes and the total cost of care for our members. We ve found that this new process, which includes the opportunity to submit treatment requests online, helps reduce service denials for members undergoing cancer treatment. For more information about this policy, go to UHCprovider.com > Prior Authorization and Notification > Oncology > Prior Authorization for Chemotherapy and Related Cancer Therapies. Frequently Asked Questions and Answers General Questions Q1. Who does this policy apply to? A1. This prior authorization requirement for outpatient injectable chemotherapy drugs is for all members, regardless of age, who are being treated for cancer. This policy affects UnitedHealthcare commercial, UnitedHealthcare Oxford and UnitedHealthcare Community Plan members. Q2. What if a member is receiving an outpatient injectable chemotherapy drug for a non-cancer diagnosis? A2. This policy doesn t apply for those using chemotherapy drugs for a non-cancer diagnosis. For those cases, prior authorization isn t required. However, certain outpatient injectable chemotherapy drugs for non-cancer diagnosis (e.g. rheumatoid arthritis) may require prior authorization under some benefit plans. If you have questions, please call the number on the back of the member s ID card. Claims submitted for injectable chemotherapy drugs for non-cancer will be reviewed according to applicable medical and drug policies to determine if services are eligible for coverage.

2 Q3. How will requests for prior authorization be reviewed? A3. Requests will be reviewed based on the National Comprehensive Cancer Network (NCCN) guidelines, including drug combinations, lines of therapy and treatment for disease progression. The process provides an auto-approval for NCCN-compliant regimens. An oncologist will review any remaining requests. The length of time the prior authorization is valid varies by request; however, most are valid for 365 days. Q4. If a member s benefit plan doesn t require prior authorization for outpatient injectable chemotherapy, can I request a pre-determination online? A4. Yes, you can use the online system to request a pre-determination for the majority of our members. If the website doesn t give you the option for a pre-determination, you can call the Provider Services number on the back of the member s ID card and request it. Q5. Why, after entering the member demographics during the authorization request process, was I directed to use a different process? A5. Some states mandate a specific process be followed for prior authorization for injectable chemotherapy medications. In these states, the mandated process affects fully insured and selffunded benefit plans that fall under the jurisdiction of the state, for example, non-erisa selffunded plans, such as government plans or church plans. In these instances, you ll be directed to the appropriate process. Because the authorization process is state-mandated, we re unable to allow exceptions. After receiving the correct authorization request document, you ll be contacted if more clinical information is needed. Administrative and Claims Information Q6. Does receipt of prior authorization for injectable chemotherapy guarantee my claim will be paid? A6. Unless payment is required by state law, receipt of a prior authorization doesn t guarantee claim payment. Payment for covered services is contingent upon the member s eligibility on the date of the service, reimbursement policies and the terms of your Participation Agreement. Some of the new commercial benefit plans we offer have specific requirements that may also affect reimbursement. Q7. When paying claims for injectable chemotherapy drugs, which components of the authorization process determine payment? A7. During the claims payment process, we look for an authorization for all billed injectable chemotherapy drugs (Healthcare Common Procedure Coding System codes) and the date of service. If the date of service isn t within the date range on the prior authorization approval, the claim won t be eligible for reimbursement. Doc#: PCA _

3 Q8. What if I don t obtain prior authorization for outpatient injectable chemotherapy? A8. If you don t obtain prior authorization for these services, your claim will be denied for lack of prior authorization and, as per your Participation Agreement, you won t be able to balance bill the member. Q9. Is prior authorization required for injectable chemotherapy drugs if UnitedHealthcare is the secondary payer? A9. No. If UnitedHealthcare is the secondary payer, prior authorization isn t required. Q10. Do I need to list the case number on the claim form? A10. No. You don t need to put any case number on the claim form. Q11. What date should I enter if we haven t determined the exact date to start injectable chemotherapy? A11. If you don t know the start date for the chemotherapy injections, enter the date that you submit the prior authorization request. Q12. What if I forgot to obtain prior authorization for the first cycle of injectable chemotherapy? A12. If you forgot to obtain a prior authorization for the first cycle, you should submit a request for prior authorization as soon as possible for future dates of service. You can t enter a start date earlier than the date you submit the prior authorization request. Claims for the first date of service will be denied for no prior authorization; however, your claim denial notice will tell you how to file an appeal should you choose to do so. Prior Authorization Process Q13. Where can I see completed prior authorization requests? A13. You can find completed prior authorizations at UHCprovider.com using the Prior Authorization and Notification tool on Link. To access the Prior Authorization and Notification tool, sign in to Link by clicking on the Link button in the top right corner of UHCprovider.com. Next, select the Submission and Status link under the Radiology, Cardiology and Oncology section. After providing additional information, you ll be directed to the appropriate site to search for your case. You ll need one of the following combinations to complete a search: o Care provider tax identification number (TIN), member ID number and date of birth o Care provider TIN, member ID number and name o Care provider TIN, member last name and first name, date of birth and state Completed authorizations won t be viewable on oxhp.com.

4 Q14. Will clinical information be required for a prior authorization request? A14. Maybe. Based on the diagnosis and/or the chemotherapy regimen that s been selected, you may be asked to provide additional clinical information, which may include: Prior chemotherapy regimen, if the member is being treated for metastatic disease Line of therapy, if the member has presence of metastatic disease Tumor histology and tumor marker for some tumor types to determine chemotherapy drug appropriateness (KRAS, HER2, BRAF) Any information you believe will help in evaluating the request, including co-morbidities, history of adverse reaction to chemotherapy drugs, etc. Clinical Scenarios Q15. We received a prior authorization that ll expire in a few weeks. The patient is doing well on this drug regimen and the treating physician would like to continue the regimen. What should the treating physician do? A15. To continue on the current regimen, the treating physician should submit a new prior authorization request at least two weeks before the current one expires. If we receive a request for a different injectable chemotherapy regimen, we ll terminate the previously approved requests. Q16. During the case entry, what do I do if the drug regimen proposed for the member isn t listed or if the drug I want to use has recently received FDA approval and doesn t have an assigned code? A16. If you don t see the drug regimen listed while doing a case entry, you can request a custom regimen. A new chemotherapy drug without an assigned J code will be listed three times. Each listing will have one of the unclassified codes: J3490, J3590 or J9999. A few chemotherapy drugs have more than one J code. These drugs will be listed with both the generic and brand name and the J code. Select the appropriate drug/j code entry. If you don t see the chemotherapy drug listed, you ll be asked to call in your request. Please provide the case number and the drug names to the representative. Q17. If I received prior authorization and the member experienced an adverse reaction to one of the chemotherapy drugs, can I change the chemotherapy drug without obtaining a new prior authorization? A17. No. If you plan to use a new injectable chemotherapy drug, you need to submit a new prior authorization request.

5 Q18. If a member has a reaction to one of the injectable chemotherapy drugs that was authorized, and I decide to drop one of the authorized drugs from the regimen, will this affect my prior authorization? A18. No. If you decide to drop a previously authorized drug from a chemotherapy regimen, it won t terminate or affect the authorization. The only time the authorization is affected is when you are adding a medication. Q19. If my patient has a medical contra-indication to an NCCN-recommended regimen, what should I do? A19. You can submit clinical information to support your decision for a non-nccn recommended regimen during the prior authorization process. An oncologist will review all information before we make a coverage decision. Q20. The NCCN doesn t address pediatric cancers, so what s used to review requests for injectable chemotherapy regimens for pediatric patients? A20. Outpatient injectable chemotherapy for pediatric patients requires prior authorization to be eligible for payment. According to our policies, we ll cover all chemotherapy agents for those younger than age 19 because the majority of pediatric patients receive treatments based on national pediatric protocols that are similar to the NCCN patient care guidelines. Q21. The NCCN doesn t address rare adult cancers, so what s used to review requests for injectable chemotherapy regimens for adults with rare cancers? A21. An oncologist will review requests for outpatient injectable chemotherapy for patients with rare cancers against current peer-reviewed published literature. During your case submission, we encourage you to provide any clinical information or published documentation that supports your choice of chemotherapy regimen. Q22. If a member is going to receive an injectable chemotherapy regimen of AC followed by T with Trastuzumab and the first four cycles of chemotherapy only include doxorubicin and cyclosphosomide, should I authorize the entire regimen for all four drugs or only the drugs used in the first four cycles? A22. In this case, you d authorize the entire regimen. During the authorization process, if the chemotherapy regimen is recommended by the NCCN for the member s clinical condition, select the entire regimen (AC followed by T with trastuzumab). The authorization period for all regimens, including trastuzumab, is 14 months. Non-trastuzumab adjuvant regimens are authorized for eight months; metastatic regimens for 12 months. We ll provide you with the resulting expiration date for prior authorization for the chemotherapy regimen. For this example, the authorization would include all four of the chemotherapy agents in the regimen and the time span of the authorization. If you request a new injectable chemotherapy drug and we approve a new authorization, the old prior authorizations will expire as of the date of the new request.

6 Questions Q23. Who can I contact if I need more information? A23. If you have questions about this policy, please send an to unitedoncology@uhc.com. Insurance coverage provided by or through UnitedHealthcare Insurance Company, All Savers Insurance Company, Oxford Health Insurance, Inc. or their affiliates. Health Plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare Benefits Plan of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Texas, LLC, UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc. and UnitedHealthcare of Washington, Inc., Oxford Health Plans (NJ), Inc. and Oxford Health Plans (CT), Inc. or other affiliates. Administrative services provided by United HealthCare Services, Inc., OptumRx, OptumHealth Care Solutions, LLC, Oxford Health Plans LLC or their affiliates. Behavioral health products are provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates. 1 Coverage decisions for chemotherapy requests for Rhode Island UnitedHealthcare Oxford members and chemotherapy requests by Rhode Island physicians for UnitedHealthcare Oxford members will be determined by Oxford, not evicore.