Provider Update
​Provider Updates

Prior Authorization List Additions –

  1. Miscellaneous Medication Codes on Medical Benefit PA List
    • When new medications are approved by the FDA and enter the market they generally do not have their own codes
    • Providers bill these medications under a variety of “miscellaneous” codes until a permanent code is assigned (usually within 12 – 24 months)
    • The following language has been added to the Prior Authorization list: “Medications billed under miscellaneous codes (examples; J3490, J3590) with amount billed > $500”

  1. Effective 4/1/17 – recently added to the Medication Prior authorization list – Buprenophine Implant (Probuphine).
  • Buprenophine Implant – implant for the maintenance treatment of opioid dependence in patients Prior authorization will be required for buprenorphine (Probuphine) implant effective April 1, 2017.  The current codes utilized for this medication include J3490 or C9399.  

​Advanced Care Planning and Palliative Care Training Update –

Advanced Care Planning (ACP) and / or palliative care consultations are conversations offered to any person over 18 years of age to record basic preferences for care and to identify a health care agent in the event that the individual loses decision-making capacity. This service improves shared decision-making between the physician and patients diagnosed with a terminal illness.

Effective February 1, 2017, completion of ACP training needed for certification is no longer a credentialing requirement by Unity Health Insurance. 

Clinicians interested in additional ACP training have access to a range of options. Listed below are several Wisconsin Medical Society accredited ACP 30-minute training webinars for physicians interested in ACP certification. Physicians who are members of the Wisconsin Medical Society or members of an organization that participates in Honoring Choices Wisconsin (HCW) are eligible for the lower member price.

  1. Clinical training and guidance: HCW trains participating organizations to build strong advance care planning systems in clinical settings.  To date, 30 state health care organizations have completed the training. Participants begin with a small-scale, six-month trial implementation and use the lessons learned to facilitate the approach throughout the organization. The concepts, methodologies, training systems and materials are based on Respecting Choices® First Steps®, a pioneering program in advance care planning based in La Crosse. Respecting Choices® faculty provides training and consultation from the first days of implementation through sustainability. More information can be found on the HCW website.

  2. Advance Care Planning CME webinars: Seven webinars of 30 minutes (0.50 CME credit) and one webinar of 60 minutes (1.00 CME credit) are available on a range of ACP topics addressing the following objectives –

    1. Define advance care planning as a process of understanding, reflecting on and discussing future medical decisions, including end-of-life preferences
    2. Describe the benefits of advance care planning for patients, families and health care professionals
    3. Identify strategies for incorporating advance care planning into routine health care
    4. Implement communication strategies to better initiate and conduct advance care planning conversations
  3. Advance Care Planning PI CME / MOC Part IV:  The Society’s Improving Advance Care Planning activity brings together physicians and their staff to engage in performance improvement by evaluating current practice and identifying opportunities to improve patient care. This activity starts with a two hour facilitated conversation among the physicians, leadership and quality staff that result in meaningful dialogue and participation. Physicians apply the performance improvement (PI) process with a focus on communi­cation and interpersonal skills, as well as systems and workflow interventions. Physicians earn AMA PRA Category 1 Credits™ and Maintenance of Certification (MOC) Part IV credit.

Hearing Aid Coverage

Some Unity plans provide coverage for one hearing aid per ear every 36 months.  Changes to the Covered Hearing Aid list are made each year.  Please check the brands and specific models covered for those who have hearing aid benefits.* 

*Hearing aids must be obtained from a participating Unity provider. Participating hearing aid providers must submit both the appropriate code and the specific manufacturer and model on the claim for correct processing.

Advance Care Planning CPT Codes

CPT codes identified by CMS and AMA that may be submitted for Advance Care Planning services for reimbursement are–

  • CPT 99497: Advance care planning including the explanation and discussion of advance directives, by the physician or other qualified health care professional; first 30 minutes
  • CPT 99498: Each additional 30 minutes of CPT 994