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New and Updated Policies Now Available Online
Payment Integrity Policies
The Payment Integrity Administrative Policy: Pre/Post Pay Claim Reviews criteria is being formalized in policy format effective Aug. 1, 2021. We routinely evaluate claims for coding, billing accuracy, and appropriateness. Providers are required to supply requested supporting information such as itemized bills and medical records. It is the billing provider’s responsibility to ensure their responses are both prompt and complete. Note: Neither additional records nor amended records will be accepted once an audit review is complete.
Enterprise Version
In addition, we are adding outpatient APC audits to our payment integrity correct coding evaluations effective Aug. 1, 2021. We have contracted with Optum to perform these audits on our behalf. Notification via letters, their audit findings, and instructions on how to appeal their determinations will be coming directly from Optum.
Reimbursement Policies
All Reimbursement Policies are available for download from our provider websites.
EmblemHealth
ConnectiCare
Coding Updates
Effective Aug. 31, 2021, the Diagnosis Code Guidelines: Manifestation/Secondary Diagnosis Codes is a new policy added for EmblemHealth to address Manifestation and Secondary Diagnosis Codes. EmblemHealth will follow the ICD-10-CM Official Guidelines for Coding and Reporting.
EmblemHealth
ConnectiCare
Effective Sept. 1, 2021, we are introducing these new and updated policies:
Modifier JW – Drug and Biologicals – Modifier JW is appended when a physician, hospital, or other provider/supplier must discard the remainder of a single use/dose vial or other single use/dose package after administering a dose of the drug or biological. Reimbursement will be made for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label provided appropriate criteria are met. Per CMS, it is not appropriate to bill discarded or wasted amounts of drugs from multi-dose vials/multi-use packages with modifier JW; these claims will be denied. Note: A drug billed with modifier JW Is not payable when another claim line does not exist for the same drug on the same date of service. To minimize waste, the units billed must correspond with the smallest dose (vial) available for purchase from the manufacturer(s) that could provide the appropriate dose for the patient.
EmblemHealth
ConnectiCare
The Modifier Reference Policy (Commercial) has been updated to align certain codes with CMS.
EmblemHealth
ConnectiCare
The Multiple Endoscopy-Pay Percent is a new policy. We will begin editing endoscopic procedure codes billed to align with CMS guidelines. Edits will apply to multiple endoscopic procedures performed for the same patient, by the same provider, on the same date of service. The editing rules will, for example, look for multiple endoscopies billed, determine when multiple base procedure codes in the same family are incorrectly billed, and apply the multiple procedure cutback. The Relative Value Unit will be used when calculating the multiple endoscopy reduction. In addition to an adjustment based on the multiple endoscopy and multiple surgery guidelines, adjustments may also be made based on the following concepts: Bilateral, Multiple Quantity, and Payment Modifiers.
EmblemHealth
ConnectiCare
The Never Events/Adverse Events & Serious Reportable Events (Commercial) policy is being updated to indicate that any procedure billed with modifier PA (Surgical or other invasive procedure on wrong body part), PB (Surgical or other invasive procedure on wrong patient), or PC (Wrong surgery or other invasive procedure on patient) is not payable.
EmblemHealth
ConnectiCare
The Co-Surgeon/Team Surgeon – Modifiers 62/66 is a new policy intended to serve as a general reference guide for the appropriate use of modifiers 62 or 66 when appended to procedures submitted on professional claims for physicians or other qualified health care professionals.
EmblemHealth
ConnectiCare
The Team Surgery Policy (Modifier 66) a is new update to the ConnectiCare Coding Edits Policy. Procedures billed with modifier 66 are not payable when there exists a previously processed claim for the same procedure code without modifier 66 by any provider in accordance with CMS’s guidelines.
ConnectiCare
EmblemHealth has instituted a payment policy for duplicate claims for drugs effective Sept. 15, 2021.
New Coding Policies
Effective Oct. 1, 2021, we are introducing these 11 new coding policies:
The Medically Unlikely Edits (MUE) – Outpatient and Medically Unlikely Edits (MUE) – Practitioner policies will identify claim lines where the CMS Facility or Practitioner MUE has been exceeded for a CPT/HCPCS code with MUE adjudication indicator (MAI) = 1, 2 or 3, reported by the same provider, for the same member, on the same date of service. This rule will evaluate date ranges to determine if the MUE has been met or not.
The Unbundled Pair (CMS) policy will identify claim lines containing Procedure Codes that are typically not recommended for reimbursement when submitted with certain other Procedure Codes on the same date of service. Provider matching will be based on Tax Identification Number (TIN) and Specialty.
The Pay Percent Professional EM Rule applies pay percent recommendations to professional claims when a well visit/preventive exam, and any other Evaluation and Management (E&M) code(s), are billed for the same patient, same provider, and same date of service regardless of any modifiers.
The LCD Procedure/Diagnosis_ FREQ_ Multi-diagnosis Rule identifies Professional and Outpatient Facility claim lines for certain procedure codes associated with a single diagnosis code/multiple diagnosis codes or no diagnosis code, modifier, age and frequency requirement where the procedure is not considered medically necessary, payable, or has payment constraints according to Local Coverage Determinations (LCDs).
The LCD Medical Necessity ICD-10 Rule identifies Professional and Outpatient Facility claim lines for certain procedure codes associated with diagnoses where the procedure is not considered medically necessary, payable, or has payment constraints according to Part A and Part B Local Coverage Determinations (LCDs).
The NCD Procedure to Diagnosis - Exclusionary Lab Rule identifies Professional and Outpatient Facility claim lines where laboratory procedures are not considered medically necessary or payable according to the Centers for Medicare and Medicaid Services (CMS) National Coverage Policy for Laboratory Procedures.
The NCD Procedure to Diagnosis - Inclusionary Lab Rule: Identifies Professional and Outpatient Facility claim lines where laboratory procedures are not considered medically necessary or payable according to the Centers for Medicare and Medicaid Services (CMS) National Coverage Policy for Laboratory Procedures. This Inclusionary policy is based on the CMS defined list of "ICD-10-CM Codes Covered by Medicare Program".
The NCD Procedure to Diagnosis - Non-Covered Rule identifies Professional and Outpatient Facility claim lines submitted for procedure codes paired with specific diagnoses for which that code pair is defined as non-covered or not payable according to the Centers for Medicare and Medicaid Services (CMS) National Coverage Determination Policy (NCD).
The NCD Procedure to Diagnosis - Covered Rule identifies Professional and Outpatient Facility claim lines for procedure codes not submitted with a covered diagnosis and is therefore defined as non-covered or not payable according to the Centers for Medicare and Medicaid Services (CMS) National Coverage Determination Policy (NCD).
The NCD Procedure to Diagnosis Coverage Rule identifies Professional and Outpatient Facility claim lines for certain procedure codes associated with a single diagnosis code/multiple diagnosis codes or no diagnosis code, modifier, age and frequency requirement where the procedure is not considered medically necessary, payable, or has payment constraints according to National Coverage Determinations (NCDs).
EmblemHealth
ConnectiCare
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