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Compliance Updates

Practicefirst would like to inform you of the recent Univera updates communicated to us. These updates can also be found on the website https://provider.univerahealthcare.com.

These updates are essential as they hold NCD and LCD information for medical necessity and policy updates. The following have been updated:

As of April 1, 2022 

Medical Necessity Review Criteria: 

Effective July 1, 2022, all requested inpatient mental health and substance use services for Medicare members will be reviewed for medical necessity based on Medicare National Coverage Determinations (NCD) and Local Coverage Determinations (LCD). 

As of April 15, 2022

Electrical Stimulation Medical Policy Update 

Effective July 15, 2022, Corporate Medical Policy 1.01.01 Transcutaneous and Percutaneous Electrical Nerve Stimulation replaces 1.01.01 Electrical Stimulation. The policy has been updated to reflect the Centers for Medicare and Medicaid Services for coding changes and address the new technology approved by the U.S. Food and Drug Administration. For further information, please log on to the website https://provider.univerahealthcare.com. 

As of April 15, 2022 

Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members 

Effective July 15, 2022, Corporate Medical Policy 7.01.84 Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members has been updated to reflect New York State guidelines and the World Professional Association for Transgender Health (WPATH) recommendations. This policy applies to Commercial (HMO, PPO, POS, FEP, ASO/ASC, Indemnity and Essential Plans) and Medicare Advantage plans and the services of all practitioners and facilities. The Gender Affirming Surgery and Treatments for Commercial and Medicare Advantage Members policy updates the criteria for treating gender dysphoria. The rationale section of the medical policy provides further information relating to the health plan’s changes in coverage.

As of April 15, 2022 

Transcatheter Heart Valve Procedures Corporate Medical Policy

Effective July 15, 2022, The new corporate medical policy merges CMP#7.01.107 Transcatheter Aortic Valve Implantation for Aortic Stenosis and CMP#7.01.108 Transcatheter Mitral Valve Repair and adds criteria for the procedures of transcatheter pulmonary valve implantation and transcatheter tricuspid valve repair or replacement. The policy applies to the services of all practitioners and facilities 

Please refer to the Univera provider link for further information. Also, as a reminder: please confirm member eligibility and authorization requirements at https://wnyhealthenet.com/ before rendering the services. Final determinations and coverages are subject to the member’s benefits and eligibility on the service date.

For Compliance questions, please contact Sandra Setlock at 716-389-3236 or sandys@pracfirst.com. 

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