Date>

<Oxford NJ Employer Group Contact/BA Name>

<Address 1>

<Address 2>

<City>, <State> <ZIP Code>

RE: Post-Service Medical Necessity Determination

Dear Valued Oxford Client,

We are writing to you, today, to inform you about a Post-Service Medical Necessity Determination policy that we are implementing, beginning Jan. 1, 2013.

The policy pertains to claims submitted to us for Oxford members who have received certain non-emergent outpatient radiology services ordered by their provider.

Outpatient Radiology Services subject to
Pre- / Post-Service Medical Necessity Determination include*
  • Magnetic Resonance (MRI/MRA)

  • Computed Tomography (CT Scan)

  • Positron Emission Tomography (PET Scan)

  • Nuclear Medicine and Nuclear Cardiology

  • Ultrasound

*No medical necessity review of these services is required when they are performed in an

emergency room/department, ambulatory surgery center, urgent care facility, or during an

inpatient stay. Oxford[1] has engaged CareCore National to perform medical necessity reviews.

What’s changed?

If a provider does not seek medical necessity determination in advance of a member’s non-emergent outpatient radiology service, the member’s claim will be subject to Post-Service Medical Necessity Determination. Under Post-Service Medical Necessity Determination, we will request medical notes and records from the member’s provider. While providers of these services are not required to obtain a medical necessity determination prior to delivering these services, they may do so at their option or at the member’s request.

Why we’re implementing this policy

The Post-Service Medical Necessity Determination policy is in compliance with your New Jersey Certificate of Coverage, and the policy brings all of our OxfordNew Jersey clients in line with a review requirement for non-emergent outpatient radiology services.

How the Post-Service Medical Necessity Determination may impact you or your covered employees

We want you and your employees to be informed of the policy and reminded that youshould continue to seek health care services from participating (Oxford network) providers in order to maximize your benefits coverage. When members use a participating radiology provider, there will be no impact to the member if the service is determined to be not medically necessary. However,if a member’s outpatient radiology service is performed by a non-participating provider (i.e., out-of-network), the member may be responsible for the entire bill.

Additional communications

We have informed participating providers of the Post-Service Medical Necessity Determination by letter, and information has been posted to the Messages section of the Provider and Member portals on oxfordhealth.com.

Please contact your Oxford representative if you have questions about this notice. Members can call the telephone number on their health plan ID card for assistance.

Thank you for your attention to this important information. We value your business and look forward to continuing our service to you and your employees.

Wishing you the best of health.

Sincerely,

<Oxford Representative Name

<Oxford Representative Title>

NJ-12-1061 (Oxfordsmall group, municipality and school board plan groups, individual members)

[1]Oxford HMO products are underwritten by Oxford Health Plans (NJ), Inc. Oxford insurance products are underwritten by Oxford Health Insurance, Inc. Administrative services provided by Oxford Health Plans LLC.