This is a reminder that important changes to the list of services and drugs that require precertification are in effect for Medicare Advantage HMO members for dates of service on or after January 1, 2012.

The following precertification requirements have been added for Medicare Advantage products in all settings:

• potentially cosmetic procedures (please refer to the complete list in the October 2011 edition of Partners in Health Update^SM);
• pain management procedures (i.e., paravertebral facet joint injections, transforaminal epidural injections, epidural injections);
• hyperbaric oxygen treatments;
• additional medical infusion/injectable drugs (please refer to the complete list in the October 2011 edition of Partners in Health Update);
• cataract surgery;
• cochlear implant surgery;
• uvulopalatopharyngoplasty (UPPP or UP3).

The following precertification requirements have been removed for Medicare Advantage products in all settings:

• sleep studies
• cardiac rehabilitation
• pulmonary rehabilitation

It is very important that providers continue to refer to the most current precertification requirements list or to use the NaviNet? web portal to verify member-specific requirements. Failure to obtain precertification for any of the services or drugs that require it may result in a reduction in payment or nonpayment for the services not precertified.

Please call 1-800-275-2583 if you have any questions about these upcoming changes.

Note: These changes went into effect for Pennsylvania and Delaware commercial members for dates of service on or after September 1, 2011. Changes will also be made for New Jersey commercial members, but the effective date has yet to be determined. More information will be available in future editions of Partners in Health Update.

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