• J0881     Darbepoetin alfa (non ESRD use),
• J0882     Darbepoetin alfa (ESRD use),
• J0885     Epoetin alfa (non ESRD use),
• J0886     Epoetin alfa (ESRD use),
• Q4081    Epoetin alfa (ESRD on dialysis).

The EPO drug policy applies to commercial EPO claims where UnitedHealthcare is primary.  It does not apply when Medicare is primary or on commercial EPO claims where UnitedHealthcare is secondary.

For 837(P) electronic claims submitted to UnitedHealthcare, our claims system is able to auto adjudicate EPO claims when the hematocrit is in the 2400 Loop, MEA field.

When the Hct value is not in that data field, the claim is pended and a letter is sent to the physician asking for the Hct level.  We realize that even though we have contacted physician offices about the issue, the problem may rest with EDI vendors - many EDI vendors are not submitting the Hct to UnitedHealthcare in the MEA field.  Additional reasons for claims not adjudicating appropriately include the submission of a hemoglobin level (rather than hematocrit), and where the EDI vendor is not able to display the decimal point when forwarding the claim to UnitedHealthcare (for example, an Hct of 33.3, is sent to UnitedHealthcare as 333).

For the next few weeks, we anticipate that we and physician offices will be working closely with EDI vendors to improve the data exchange.  During the transition period, we have established a program to accept the Hct details via a spreadsheet instead of requiring the submission of a corrected claim with the Hct. * 

(* Please review instructions and criteria for use of spreadsheet for Hct level submission.  This process is only available for claims with a date of service for 4/2/07 to 5/31/07).

This resubmission method will only work if you have already submitted a claim to UnitedHealthcare for the EPO services.  We will populate the Loop 2400 MEA field with the Hct level, and the claim will be reprocessed.  Payment may take up to 4 - 6 weeks; but should greatly simplify the process of forwarding the Hct levels to UnitedHealthcare.

For those of you submitting paper claims to UnitedHealthcare, the Hct level should be placed in field 24k of the HCFA 1500 claim form or in field 24a of the revised 1500 Health Insurance Claim Form.  Our keying staff has been trained to look in these locations for this information.  Information in other area's of the claim form may be overlooked.  The resubmission process outlined below will also work for a paper claim submitted without the Hct level.

Instructions for Use of Spreadsheet for Hct level Submission:

      1.  Download the spreadsheet template.

      2.  Complete the spreadsheet with the following data fields:

• Provider TIN or NPI
• Provider First Name
• Provider Last Name
• Subscriber ID
• Patient ID
• Patient First Name
• Patient Last Name
• Patient DOB
• DOS
• J Code
• Hct level

    3.  Please add a statement to your submission acknowledging that the attached document accurately reflects clinical information in connection with the submitted claims.

    4.  If you have secure email capabilities, forward the spreadsheet and attestation to unitedoncology@uhc.com.  If you do not have secure email capabilities, we ask that you download the information to a disk and forward via overnight mail to:  Attn:  Ranae Dahlberg, UnitedHealthcare, Mail Route:  MN012-S203, 5901 Lincoln Drive, Edina, MN  55436, (952) 992-6000.

This process will be an option for submitting the Hct for EPO claims that meet the following criteria:

• EPO claim has already been sent to UnitedHealthcare
• Date of Service (DOS) is between 4/2/2007 and 5/31/2007
• EPO claim has been pended and UnitedHealthcare has requested the Hct level, or
• A denial letter has been received and you believe the denial may be related to a hemoglobin level submitted, or a decimal point error.

During this transition period, we ask that you continue to review your claims submission process, checking with all EDI vendors to assure that in the future you will be able to submit EPO claims electronically to UnitedHealthcare with the Hct level in the Loop 2400, MEA field. 

Additionally, we would like to note an error in our EPO claim instructions booklet that included an option for submitting a corrected claim via UnitedHealthcareOnline.com.  Unfortunately, our system process is not working at this time.  Individuals that attempt to use this function will receive an error message instructing them to submit the information via paper.  We apologize for any inconvenience your office has experienced due to this system issue.  Please reference our claim instructions for paper corrected claim submission instead.

Related Links EPO Hct Submission Spreadsheet  Erythropoietin (EPO) Claim Submission Instructions