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    Prior Authorization - Physician Practice Page

    MSNJ's  2017 House of Delegates Resolution Substitution 4A: Prior Authorization asked that MSNJ study the problems of prior authorization; compile prior authorization measures online; and work with the New Jersey Department of Banking and Insurance (NJ DOBI) and payers to streamline the process. 

    Below are links to payer prior authorization policies available online. This is not a comprehensive list, as many policies were only available to physicians through payer portals and payer policies change frequently. These links will be updated periodically; however, we cannot guarantee the accuracy or timeliness of the information provided. Before providing a service to a patient, it is recommended that you directly access the payer portal and contact the plan to determine whether prior authorization is required. 

    TABLE OF CONTENTS: BY PAYER

    1. Aetna
    2. Aetna Better Health of NJ (Medicaid MCO)
    3. Aetna Medicare Advantage
    4. Amerigroup (Medicaid MCO)
    5. AmeriHealth
    6. Cigna
    7. Clover Health (Medicare Advantage)
    8. Horizon
    9. Horizon Medicare Blue
    10. Horizon NJ Health (Medicaid MCO)
    11. Medicare
    12. Oxford
    13. Qualcare
    14. United Healthcare
    15. United Healthcare Community Plan (Medicaid MCO)
    16. United Healthcare Medicare Solutions
    17. Wellcare (Medicaid MCO)
    18. Wellcare (Medicare Advantage)

     

    Aetna

    Medical & Pharmaceutical

    • Participating provider precertification list (effective 09/01/17)
      • List of plans policy applies to: All Aetna plans, except Traditional Choice® plans; All Innovation Health® plans, except indemnity plans; All Health benefits and health insurance plans offered and/or underwritten by Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna)

    Behavioral

    • Behavioral health precertification list (effective 03/01/17)
      • This policy applies to all Aetna plans with the exception of:• Behavioral health benefits plans that we administer, but do not manage• Self-funded plans with plan sponsors who have expressly purchased precertification requirements. Aetna Choice® POS, Aetna Choice POS II, Aetna MedicareSM Plan (PPO), Aetna MedicareSM Plan (HMO), all Aetna HealthFund® products, Aetna Health Network OnlySM, Aetna Health Network OptionSM, Aetna Open Access® Elect Choice®, Aetna Open Access HMO, Aetna Open Access Managed Choice®, Open Access Aetna SelectSM, Elect Choice, HMO, Managed Choice POS, Traditional Choice, Open Choice, Quality Point-of-Service® (QPOS®) benefits plans, Choose and SaveSM, Savings Plus, Aetna SelectSM benefits plans and all products that may include the Aexcel® networks** and include the designation Aexcel or Aexcel Plus.

    Aetna Better Health of NJ (Medicaid MCO)

    Medical

    Pharmaceutical

    Aetna Medicare Advantage

    Pharmaceutical

    Amerigroup (Medicaid MCO)

    Pharmaceutical

     Medical

    AmeriHealth

    Medical

    Pharmaceutical

    Cigna

    Medical

    Pharmaceutical

    Clover Health (Medicare)

    Medical

    Pharmaceutical

    Horizon

    Medical

    Pharmaceutical

    Horizon Medicare Blue

    Medical

    Pharmaceutical

    •  Look-up tool
    • List of plans policy applies to: Formularies for each plan on Prime Therapuetics website (requires login): Horizon Medicare Blue Patient-Centered w/Rx (HMO), Horizon Medicare Blue Value w/Rx (HMO), Horizon Medicare Blue Choice w/Rx (HMO), Horizon Medicare Blue (PPO), Horizon Medicare Blue Enhanced (PDP), Horizon Medicare Blue Standard (PDP), Horizon NJ TotalCare (HMOSNP)

    Horizon NJ Health (Medicaid MCO)

    Medical

    Pharmaceutical

    Medicare

    Medical

    Oxford

    Medical & Pharmaceutical

    • SERVICES REQUIRING PRIOR AUTHORIZATION Policy Number: ADMINISTRATIVE 245.46 (effective 08/01/17)
      • List of plans policy applies to: Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. The term Oxford includes Oxford Health Plans, LLC andall of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products.

    Pharmaceutical

    Qualcare

    Medical

    United Healthcare

    Medical

    • United Healthcare Notification/Prior Authorization Requirements (effective 07/01/17)
    • United Healthcare Cardiology Prior Authorization Program Quick Reference Guide: Commercial (effective 04/19/17)
      • Forms
      • More information
      • List of plans policy applies to: Commercial. The following Commercial benefit plans are excluded from the protocol. • UnitedHealthcare Options PPO (Care providers are not required to follow this protocol for our Options PPO benefit plans because members enrolled in these benefit plans are responsible for providing notification/requesting prior authorization. The exception to this is care providers who treat Options PPO benefit plans for members in Colorado because they are not responsible for providing notification/requesting prior authorization). • UnitedHealthOne - Golden Rule Insurance Company (“GRIC”) group number 705214 only • M.D. IPA, Optimum Choice, Inc., or OneNet • Oxford (USA, New Jersey Small Group, certain NJ public sector groups, CT public sector, Brooks Brothers (BB1627) and Weil, Gotshal and Manages (WG00101), any member at VAMC facility). • UnitedHealthcare Indemnity/Managed Indemnity • Sierra • Benefit plans sponsored or issued by certain self-funded employer groups. The protocol does not apply to non-Commercial benefit plans such as Medicare Advantage, Medicaid, CHIP or Uninsured. Members of these plans are subject to the administrative guide, member manual or supplement of that affiliate. Any existing requirements regarding notification, authorization and/or precertification for the above listed excluded entities remain in place and are not impacted by the Commercial Cardiology Prior Authorization Program
    • Commercial Intensity Modulated Radiation Therapy Program (accessed 09/22/17)
      • Forms
      • More information
      • List of plans policy applies to: Prior Authorization for Intensity Modulated Radiation Therapy (IMRT) services is required for members of the following Commercial health plans: UnitedHealthcare, UnitedHealthcare West, UnitedHealthcare of the Mid-Atlantic, UnitedHealthcare Plan of the River Valley, Neighborhood Health Partnership
    • Commercial: Radiology Notification & Prior AuthorizationCPT Code List (accessed 09/22/17)
      • Forms
      • More information
      • The protocol applies to certain UnitedHealthcare Commercial benefit plans that are subject to the UnitedHealthcare Provider Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement. The following Commercial benefit plans are excluded from the protocol. • UnitedHealthcare Options PPO (Providers are not required to follow this protocol for Options PPO benefit plans because members enrolled in these benefit plans are responsible for providing notification/ requesting prior authorization. However, providers are required to follow this protocol for Options PPO benefit plans for members in Colorado because Colorado members are not responsible for providing notification/requesting prior authorization). • UnitedHealthOne - Golden Rule Insurance Company (“GRIC”) group number 705214 only • M.D.IPA, OneNet or Optimum Choice, Inc., or OneNet • UnitedHealthcare Indemnity/Managed Indemnity • Oxford (USA, New Jersey Small Group, certain NJ public sector groups, CT public sector, Brooks Brothers (BB1627) and Weil, Gotshal and Manages (WG00101), any member at VAMC facility). • Sierra • Benefit plans sponsored or issued by certain self-funded employer groups. The protocol does not apply to non-Commercial benefit plans such as Medicare Advantage, Medicaid, CHIP or Uninsured. Members of these plans are subject to the administrative guide, manual or supplement of that affiliate. Any existing requirements regarding notification, authorization and/or precertification for the above listed excluded entities remain in place and are not impacted by the Radiology Notification/Prior Authorization Program.

    Pharmaceutical

    • Avastin Expanded NCCN Review for Prior Authorization (accessed 09/22/17)
      • More information
      • List of plans policy applies to: Prior authorization for Avastin is required under the Injectable Chemotherapy Prior Authorization Program for the following health plans: UnitedHealthcare Oxford Health Plans, UnitedHealthcare Individual & Employee Plans (excluding Indemnity / PPO membership), Neighborhood Health Partnership, UHOne, Golden Rule Insurance Company, UnitedHealthcare Life Insurance Company, UnitedHealthcare Community Plans for select states; see the Injectable Chemotherapy Prior Authorization Program for details
    • Prior Authorization for Outpatient Injectable Chemotherapy and Colony-Stimulating Factors (accessed 09/22/17)
      • Forms
      • More information
      • List of plans policy applies to: UnitedHealthcare benefit plans typically require prior authorization for injectable chemotherapy. The following lists show the effective date of the prior authorization requirement. UnitedHealthcare Commercial plans, excluding Indemnity/Options PPO – June 1, 2015; UnitedHealthcare Community Plan Arizona Members: Arizona Health Care Cost Containment System/Medicaid and Developmentally Disabled - October 1, 2015; UnitedHealthcare Community Plan Delaware Members: Delaware Community Plan, excluding Long Term Care and UnitedHealthcare Dual Complete (HMO SNP) - January 1, 2017; UnitedHealthcare Community Plan Florida Members – May 17, 2014; UnitedHealthcare Community Plan Maryland Members: HealthChoice- April 1, 2016; UnitedHealthcare Community Plan Tennessee Members: TennCare - June 1, 2016; UnitedHealthcare Community Plan Washington Members: Apple Health - May 1, 2016; UnitedHealthcare Community Plan Michigan Members: Medicaid, excluding CSHCS and UnitedHealthcare Dual Complete (HMO SNP) - October 1, 2016; UnitedHealthcare Community Plan Mississippi Members: Mississippi Coordinated Access Network (MSCAN) and Mississippi Children's Health Insurance Program (MSCHIP), excludes  UnitedHealthcare Dual Complete (HMO SNP) - October 1, 2016; UnitedHealthcare Community Plan New Jersey: New Jersey FamilyCare, this change does not impact members enrolled in the Dual Complete One plan - January 1, 2017; UnitedHealthcare Community Plan New York Members: Medicaid Managed Care (MMC), Child Health Plus (CHPlus), Health and Recovery Plan (HARP) otherwise known as Wellness4Me, and Essential Plan. UnitedHealthcare Dual Complete® (Medicare Advantage plan), UnitedHealthcare Dual Advantage (Medicaid Advantage) and Managed Long Term Care (UnitedHealthcare Personal Assist) are excluded from this requirement. - February 1, 2017; UnitedHealthcare Community Plan Ohio Members: Medicaid - October 1, 2016; UnitedHealthcare Community Plan Pennsylvania Members: Medicaid and CHIP - February 1, 2017; UnitedHealthcare Community Plan Texas Members: CHIP, STAR, STAR+PLUS, and STAR Kids: does not apply to UnitedHealthcare Connected (Medicare and Medicaid Plan) and UnitedHealthcare Dual Complete HMO SNP. - January 1, 2017; UnitedHealthcare Community Plan Wisconsin Members: Badger Care - October 1, 2016; UnitedHealthcare Life Insurance Company2,  select group members - June 1, 2015; UnitedHealthcare Oxford Commercial Plans1 – February 1, 2016; Golden Rule Insurance Company2, select group numbers – June 1, 2015; Neighborhood Health Partnership – May 17, 2014
    • 2017 Prescription Drug List (effective 07/01/17)

    United Healthcare Community Plan (Medicaid MCO)

    Medical

    Pharmaceutical

    United Healthcare Medicare Solutions

    Medical

    • Medicare Advantage Therapeutic Radiation Prior Authorization Program (accessed 09/22/17)
    • UnitedHealthcare Medicare Solutions and UnitedHealthcare Community Plan – Medicare Prior Authorization Requirements (effective 07/01/17)
      • Forms
      • More information
      • List of plans policy applies to: Medicare Advantage HMO, HMO-POS, PPO and Regional PPO plans including AARP® MedicareComplete®, UnitedHealthcare®, The Villages®, MedicareComplete®, UnitedHealthcare®, MedicareComplete® plans for both individual and employer group members, and group retiree plans sold under UnitedHealthcare®, Group Medicare Advantage (PPO), UnitedHealthcare Dual Complete® (HMO SNP), (HMO-POS SNP), (PPO SNP), (Regional PPO SNP), UnitedHealthcare® Chronic Complete (HMO SNP), UnitedHealthcare®, Nursing Home and UnitedHealthcare®, Assisted Living Plans (HMO SNP), (HMO-POS SNP), (PPO SNP), Oxford Mosaic Network Care Improvement Plus® Products: Gold Rx (PPO SNP and Regional PPO SNP), Medicare Advantage (PPO and Regional PPO), Silver Rx (Regional PPO SNP), Dual Advantage (Regional PPO SNP)
    • UnitedHealthcare Medicare Advantage Cardiology Prior Authorization Program; Quick Reference Guide (effective 12/15/16)
    • Radiology Notification & Prior Authorization CPT Code List: Medicare (effective 12/14/16)
      • Forms
      • More information
      • The following listed plans require prior authorization for in-network radiology services: Subject to the UnitedHealthcare Provider Administrative Guide and the UnitedHealthcare West Non-Capitated Supplement. Medicare Advantage HMO, HMO-POS, PPO and Regional PPO plans including AARP® MedicareComplete®, UnitedHealthcare®, The Villages®, MedicareComplete®, UnitedHealthcare®, MedicareComplete® plans for both individual and employer group members, and group retiree plans sold under UnitedHealthcare®, Group Medicare Advantage (PPO). UnitedHealthcare Dual Complete® (HMO SNP), (HMO-POS SNP), (PPO SNP), (Regional PPO SNP). UnitedHealthcare® Chronic Complete (HMO SNP). UnitedHealthcare Senior Care Options (HMO SNP). Oxford Mosaic Network. Care Improvement Plus® Products: Gold Rx (PPO SNP and Regional PPO SNP), Medicare Advantage (PPO and Regional PPO), Silver Rx (Regional PPO SNP), Dual Advantage (Regional PPO SNP). UnitedHealthcare Community Plan Medicare Advantage benefit plans subject to an additional manual, as further described in the benefit plansection of the UnitedHealthcare Administrative Guide 2017 at UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides. As explained in the benefit plan section, some UnitedHealthcare Community Plan Medicare Advantage benefit plans are not subject to an additional manual and are therefore subject to the Administrative Guide.

    Wellcare (Medicaid MCO)

    Medical

    Pharmaceutical

    Wellcare (Medicare)

    Medical

    Pharmaceutical

    • 2017 Comprehensive Formulary (List of Covered Drugs) Medicare Advantage Plans (effective 07/12/16)
      • Look-up tool
      • Forms
      • More information
      • List of plans policy applies to: Plans in the following states: AR, CT, FL, IL, KY, LA, NJ, NY, TX, TN, WellCare Choice (HMO/HMO-POS), WellCare Dividend (HMO/HMO-POS), WellCare Dividend Prime (HMO), WellCare Essential (HMO/HMO-POS), WellCare Plus (HMO), WellCare Preferred (HMO-POS), WellCare Value (HMO/HMO-POS) Plans in the following states: CT, HI, IL, LA, NJ, TX, WellCare Access (HMO SNP), Please Read: ‘Ohana Liberty (HMO SNP), WellCare Liberty (HMO SNP)

     

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