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January 2021 MAC Talk

Published on 

Wednesday, January 27, 2021

United Healthcare COVID-19 Prior Authorization Updates & Discharge Planning Resources

On January 8, 2021, United Healthcare updated their COVID-19 Prior Authorizations Update webpage

webpage noting that “to streamline operations for providers, we’re extending prior authorization timeframes for open and approved authorizations and we’re suspending prior authorization requirements for may services.” Further details and specific dates are available on this webpage for the following:

  • Temporary National Skilled Nursing Facility Prior Authorization Suppression,
  • Genetic and Molecular CPT Code/Prior Authorization Update Beginning Oct. 1, 2020,
  • Extensions of Existing Prior Authorizations,
  • Diagnostic Radiology for COVID-19,
  • Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS),
  • Infertility Treatment and Embry Cryopreservation – Update on Guidance and Coverage, and
  • Site of Service Reviews

On a related COVID-19 Ongoing Patient Cares Updates webpage, United Healthcare indicates that they have “a special team focused on COVID-19 discharge matters and that during the national Public Health Emergency (PHE), they “will generally respond to requests within two hours, from 8 a.m. to 8 p.m. Eastern Time.”


January 19, 2021: WPS Article – Documentation Required When Changing Patient Status from Inpatient to Outpatient

WPS posted the following information in their January 19, 2021 eNews:

“The Medical Review department is receiving insufficient documentation when a patient’s status changes from inpatient to outpatient. Documentation must show:

  • Orders and notes indicating why the facility is changing the patient status
  • Medical reason for care furnished to the beneficiary
  • Names of participants involved in decision making change to the patient’s status

Please review the documentation requirements for changing a patient’s status from inpatient to outpatient available in our resource, Documentation Tips.”


January 19, 2021: CGS Article – Redetermination Submission Checklist

CGS has developed a Redetermination Submission Checklist for Part A and Part B Providers to help you provide all of the information the MAC will need when submitting a redetermination.


January 22, 2021: Palmetto GBA JJ Updates Active Service Specific Post-Payment Medical Review List

Palmetto GBA updated their post-payment medical review lists for MAC Jurisdiction J and M.

Changes to Jurisdiction J Part A Line of Business (LOB)

Removed from List:

  • Denosumab (J0897)

Added to List:

  • Nivolumab (Opdivo®) – HCPCS J9299,
  • Ocrelizumab (Ocrevus®), 1mg – HCPCS J2350, and
  • IVIV Privigin 500mg – HCPCS J1459

Changes to Jurisdiction M Part A LOB

Removed from List:

  • Denosumab (J0897)

Added to List:

  • Nivolumab (Opdivo®) – HCPCS J9299,
  • Ocrelizumab (Ocrevus®), 1mg – HCPCS J2350,
  • IVIV Privigin 500mg – HCPCS J1459,
  • Infliximab (Remicade®) – HCPCS J1745,
  • Neuromuscular Reeducation – CPT 97112,
  • Intensity Modulated Radiotherapy (IMRT) Planning – CPT 77301, and
  • MLC Device(s) for IMRT – CPT 77338


January 25, 2021: WPS Article: Drug Screening Laboratory Tests – CERT Denials

In their eNews, WPS reported that the CERT “contractor has noted significant error findings for qualitative drug tests and quantitation of drugs screened (therapeutic drug assays and certain chemistry tests). In most cases, the independent laboratories that performed and billed the services did not submit sufficient documentation to support the medical necessity of the tests in accordance with Medicare regulations. The reminders below will help providers responding to CERT claim reviews:

  • Medicare requires a signed treating physician order or authenticated progress note identifying all tests the laboratory will perform.  
  • An unsigned requisition does not support physician intent. The CERT contractor will not consider it in a Medicare claim review.
  • The patient's medical record must include progress notes to support the medical necessity for ordering each test. The billing provider must submit these notes upon request for a Medicare claim review.

If you find documentation issues exist with your referring providers, we recommend educating your providers about these CERT review findings and applicable Medicare regulations. For more information, refer to the CMS Internet-Only Manual, Publication 100-02, Chapter 15, Section 80.6.1, “Requirements for Ordering and Following Orders for Diagnostic Tests,” and Local Coverage Determination (LCD) L34645, “Drug Testing.””

Article Author: Beth Cobb, RN, BSN, ACM, CCDS
Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Analytics at Medical Management Plus, Inc. Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth is a principle writer for MMP’s Wednesday@One weekly e-newsletter, an active member of our HIPAA Compliance Committee, MMP’s Education Department Program Director and co-developer of MMP’s proprietary Compliance Protection Assessment Tool.

This material was compiled to share information.  MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.