Benefit Criteria to Change for Evoked Response Tests and Neuromuscular Procedures for Texas Medicaid

Size: px
Start display at page:

Download "Benefit Criteria to Change for Evoked Response Tests and Neuromuscular Procedures for Texas Medicaid"

Transcription

1 Benefit Criteria to Change for Evoked Response Tests and Neuromuscular Procedures for Texas Medicaid Information posted February 15, 2013 Effective for dates of service on or after April 1, 2013, benefit criteria for evoked response tests and neuromuscular procedures will change for Texas Medicaid. Benefit Changes The following electromyography (EMG) procedure codes will no longer be a benefit of Texas Medicaid for the type of service component indicated: Procedure Codes , I/T = Medical, T= Technical component, I= Professional interpretation component Procedure codes and will no longer be a benefit when rendered in the office or home setting by psychologist providers. The following procedure codes will no longer be reimbursed to the provider types in the place of service indicated: Procedure Codes Place of reimbursed Outpatient hospital Physician 95970, 95971, 95972, 95973, 95974, 95975, 95978, Outpatient hospital Physician, nurse practitioner (NP), al nurse specialist (CNS), physician assistant (PA) Outpatient hospital Physician, federally qualified health center (FQHC) Office Independent, certified nurse midwife, facility, rural health 95860, 95861, 95863, , 95861, 95863, Office Independent, 5 Outpatient Physician, independent, nephrologist, renal

2 Procedure Codes Place of reimbursed Office Independent, radiation treatment center, facility, rural health Outpatient hospital Physician, independent, nephrologist, renal Office Independent, renal 95866, 95867, 95868, 95869, 95872, , 95868, 95869, 95872, Outpatient hospital Physician, independent, nephrologist, renal 5 Office Independent, Outpatient hospital Physician, independent, podiatrist, facility, rural health Office Independent, podiatrist, radiation treatment center, hospital, nephrologist, renal dialysis facility, rural health 95925, 95926, 95927, 95928, , 95832, 95833, 95834, 95851, Outpatient hospital NP, CNS, PA, physician, independent, certified nurse midwife, facility, rural health, 5 Office Independent, certified nurse midwife,

3 Procedure Codes 95831, 95832, 95833, 95834, Place of reimbursed 5 Outpatient hospital NP, CNS, PA, physician, independent, certified nurse midwife, facility, rural health, Office Independent, podiatrist, certified nurse midwife, hospital, facility, rural health Outpatient hospital Physician, independent, podiatrist, certified nurse midwife, hospital, facility, rural health, 95930, Office Optometrist, FQHC Outpatient hospital Optometrist, FQHC Office Independent, Outpatient hospital Physician, independent, nephrologist, renal, Office Independent, facility, rural health 95925, 95926, Office Independent, hospital, certified nurse midwife, nephrologist, renal

4 Procedure Codes 95831, 95832, 95833, 95834, 95852, 95925, 95926, 95927, 95928, Place of reimbursed 5 Inpatient hospital NP, CNS, PA, independent, certified nurse midwife, hospital, facility, rural health, Inpatient hospital NP, CNS, PA, independent, podiatrist, certified nurse midwife, hospital, facility, rural health, Inpatient hospital Optometrist, FQHC, portable X-ray supplier, radiological and physiological Inpatient hospital Independent,, Inpatient hospital FQHC 95970, 95971, 95972, 5 Inpatient hospital NP, CNS, PA 95973, 95974, 95975, 95978, I Inpatient and Optometrist, FQHC 95937, 95860, 95861, 95863, , 95866, 95867, 95868, 95869, 95870, 95872, , 95926, 95927, 95928, I Inpatient and Portable X-ray supplier, I Inpatient hospital Portable X-ray supplier, I Inpatient and 95928, I Inpatient and NP, CNS, PA, certified nurse midwife, portable X-ray supplier, radiological and physiological Hospital

5 Procedure Codes Place of I Inpatient and reimbursed FQHC 51784, T Outpatient hospital Hospital 95930, T Office FQHC 5= Total component, I= Professional component, T= Technical component The following procedure codes will no longer be reimbursed when rendered in the places of service indicated by any provider: Procedure Codes Place of 95865, T Outpatient hospital 95860, 95861, 95863, 5 Inpatient hospital 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, , 95832, 95833, 95834, 95851, 95852, 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875, 95925, 95926, 95972, 95973, 95974, 95975, 95978, Independent 5= Total component, T= Technical component The following procedure codes may be reimbursed to the specific providers and places of services indicated: Procedure Code 95921, 95922, 95923, 95970, 95971, 95972, 95973, 95974, Place of 5 Outpatient hospital Provider Types Hospital 95937, Office NP, CNS, PA, radiation treatment center

6 Procedure Code 95860, 95861, 95863, 95864, 95865, 95866, 95867, 95868, 95869, 95870, 95872, 95875, 95925, 95926, 95927, 95928, 95929, Place of Provider Types I Office Physician, NP, CNS, PA 51784, T Office NP, CNS, PA, radiation treatment center, 51784, 51785, 95930, T Outpatient hospital Radiation treatment center T Office Radiation treatment center T Office Radiation treatment center, radiological and physiological 5= Total component, T= Technical component, I= Professional interpretation component Electromyography EMG (procedure codes and 95874) will be a benefit of Texas Medicaid and will be limited to four occurrences per calendar year, same provider, any procedure. Procedure codes and may be reimbursed in the following place of service by the following provider types: Component Places of Provider Types Total Office Physician, NP, CNS, PA, portable X-ray supplier, providers Outpatient hospital Hospital providers Professional Office Physician, NP, CNS, and PA providers Inpatient hospital and Physician Technical Office Physician, NP, CNS, PA, radiation treatment center, and portable X-ray supplier, providers

7 Autonomic Function Tests AFTs are a benefit of the Texas Medicaid Program when submitted with procedure codes 95921, 95922, 95923, 95924, and Procedure codes 95921, 95922, 95923, 95924, and are limited to one per date of service, by the same provider. Some of the conditions under which AFTs may be appropriate include, but are not limited to, the following: Irregular heart rate Orthostatic symptoms Gastrointestinal dysfunction Excessive sweating Diabetic autonomic neuropathy Amyloid neuropathy Sjogren s syndrome Idiopathic neuropathy Pure autonomic failure Multiple system atrophy Distal small fiber neuropathy Reflex sympathetic dystrophy or causalgia (sympathetically maintained pain) Documentation Requirements for AFTs The reason for the referral, the specific autonomic function being tested, and a clear diagnostic impression must be documented in the client s medical record for each AFT performed. The client's medical records must clearly document the medical necessity for the AFT. The medical record documentation must reflect the actual results of specific tests (such as latency and amplitude). Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client s medical record. Supporting documentation includes, but is not limited to, the following: The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis. Evidence that the client s condition is changing rapidly, supported by the following: o o o o Diagnosis Current al signs and symptoms Prior al condition Expected al disease course

8 o Clinical benefit of additional studies. The client s medical records are subject to retrospective review. Wave form recordings obtained during the testing will aid documentation requirements in cases where a review becomes necessary. Evoked Potential Tests Each evoked potential (EP) test (procedure codes 92585, 92586, 95925, 95926, 95927, 95928, 95929, 95930, 95938, or 95939) is considered bilateral and will be limited to once per date of service, any provider, regardless of modifiers that indicate multiple sites tested. EP tests may be reimbursed up to four services per rolling year, any combination of services, any provider. Claims that are denied for exceeding the limitation may be considered on appeal with documentation that supports medical necessity. Procedure code will no longer be diagnosis restricted. Visually Evoked Potential (VEP) Tests Some of the conditions under which VEP testing (procedure code 95930) may be appropriate include, but are not limited to, the following: Identification of persons at increased risk for developing ally definite multiple sclerosis. Diagnosing, monitoring, and assessing treatment response in multiple sclerosis. Localizing the cause of a visual field defect not explained by lesions seen on CT or MRI, or by metabolic disorders or infectious disease. Evaluating the signs and symptoms of visual loss in persons who are unable to communicate (e.g., unresponsive persons, non-verbal persons). Evaluating clients who experience double vision, blurred vision, loss of vision, eye injuries, head injuries, or weakness of the eyes, arms, or legs. Motion Analysis Motion analysis (procedure codes 96000, 96001, 96002, and 96003) will be a benefit of Texas Medicaid for clients who are 3 through 20 years of age. Procedure codes 96000, 96001, 96002, and may be reimbursed to physician, NP, CNS, PA, radiological physiological providers in the office setting and to hospital providers in the outpatient setting. Procedure codes 96000, 96001, 96002, or are limited to one per date of service by the same provider, and two per rolling year, same procedure, any provider. In the following table, the procedure codes in Column A will be denied when they are submitted on the same date of service by the same provider as the procedure codes in Column B: Column A (Denied) Column B

9 95860, 95861, 95863, 95864, 95865, 95866, 95869, 95870, or , or Documentation for Motion Analysis Documentation must include the following information that indicates the client meets all the requirements for motion analysis studies. The client must be: Ambulatory for a minimum of ten consecutive steps, with or without assistive devices. At least 3 years of age. Physically able to tolerate up to three hours of testing. The reason for the referral and a clear diagnostic impression must be documented in the client s medical record for each motion analysis study performed. The client s medical records must clearly document the medical necessity for the motion analysis study. The medical record documentation must reflect the actual results of specific test. Medical necessity for reevaluation of a client (beyond the initial consultation and testing) must be clearly documented in the client s medical record. Supporting documentation must include, but is not limited to, the following: The client has new symptoms unrelated to those previously evaluated, suggestive of a new diagnosis. Evidence that the client s condition is changing rapidly, supported by the following: o Diagnosis o Current al signs and symptoms o Prior al condition o Expected al disease course Clinical benefit of additional studies The client s medical records are subject to retrospective review. For more information, call the TMHP Contact Center at

HCPCS Special Bulletin

HCPCS Special Bulletin HCPCS Special Bulletin 2018 Healthcare Common Procedure Coding System (HCPCS) Special Bulletin JANUARY 2018 NO. 13 2018 HCPCS Implementation On January 1, 2018, the Texas Medicaid & Healthcare Partnership

More information

TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL

TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL TELECOMMUNICATION SERVICES CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 TELECOMMUNICATION SERVICES Table of Contents 38.1 Enrollment......................................................................

More information

SECTION 2: TEXAS MEDICAID REIMBURSEMENT

SECTION 2: TEXAS MEDICAID REIMBURSEMENT SECTION 2: TEXAS MEDICAID REIMBURSEMENT 2.1 Payment Information............................................................. 2-2 2.2 Reimbursement Methodology....................................................

More information

Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015

Benefit Criteria to Change for PLS Drug Testing and Therapeutic Drug Assays November 1, 2015 1. Programs: 100/200 DRT Analyst: Phillip Rackley at 512-506-7019 or phillip.rackley@tmhp.com DRT Backup: Donna Shaver at 512-506-7288 or donna.shaver@tmhp.com State Stakeholders: Donna Claeys at donna.claeys@hhsc.state.tx.us

More information

Telemedicine Guidance

Telemedicine Guidance Telemedicine Guidance GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAID Revised: October 1, 2017 Policy Revisions Record Telemedicine Guidance 2017 REVISION DATE Oct. 1, 2017 SECTION REVISION

More information

Texas Medicaid. Provider Procedures Manual. Provider Handbooks. Telecommunication Services Handbook

Texas Medicaid. Provider Procedures Manual. Provider Handbooks. Telecommunication Services Handbook Texas Medicaid Provider Procedures Manual Provider Handbooks December 2017 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid

More information

CMS-1500 Billing and Reimbursement. HP Provider Relations/October 2013

CMS-1500 Billing and Reimbursement. HP Provider Relations/October 2013 CMS-1500 Billing and Reimbursement HP Provider Relations/October 2013 Agenda Common Denials for CMS-1500 CMS-1500 Claims Billing Types of CMS-1500 Claims Paper Claim Billing Fee Schedule Crossover Claims

More information

RFS-7-62 ATTACHMENT E INDIANA CARE SELECT PROGRAM DESCRIPTION AND COVERED BENEFITS

RFS-7-62 ATTACHMENT E INDIANA CARE SELECT PROGRAM DESCRIPTION AND COVERED BENEFITS The following services are covered by the Indiana Care Select Program. Dual-eligible members, those members eligible for both IHCP and Medicare, will not receive any benefits under Indiana Care Select,

More information

Optima Health Provider Manual

Optima Health Provider Manual Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating

More information

(a) The provider's submitted charge; or

(a) The provider's submitted charge; or ACTION: Final DATE: 12/20/2013 11:35 AM 5101:3-1-60 Medicaid reimbursement. (A) The medicaid payment for a covered service constitutes payment in full and may not be construed as a partial payment when

More information

OFFICIAL NOTICE DMS-2003-A-2 DMS-2003-II-6 DMS-2003-SS-2 DMS-2003-R-12 DMS-2003-O-7 DMS-2003-L-8 DMS-2003-KK-9 DMS-2003-OO-7

OFFICIAL NOTICE DMS-2003-A-2 DMS-2003-II-6 DMS-2003-SS-2 DMS-2003-R-12 DMS-2003-O-7 DMS-2003-L-8 DMS-2003-KK-9 DMS-2003-OO-7 Arkansas Department of Human Services Division of Medical Services Donaghey Plaza South PO Box 1437 Little Rock, Arkansas 72203-1437 Internet Website: www.medicaid.state.ar.us Telephone: (501) 682-8292

More information

Summary of Benefits CCPOA (Basic) Custom Access+ HMO

Summary of Benefits CCPOA (Basic) Custom Access+ HMO Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits CCPOA (Basic) Custom Access+ HMO CCPOA Effective January 1, 2019 HMO Benefit Plan This Summary of Benefits

More information

FEDERALLY QUALIFIED HEALTH CENTERS (FQHC)

FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) AND RURAL HEALTH CLINICS (RHC) CSHCN SERVICES PROGRAM PROVIDER MANUAL AUGUST 2018 CSHCN PROVIDER PROCEDURES MANUAL AUGUST 2018 FEDERALLY QUALIFIED HEALTH CENTERS

More information

Appeal Process Information

Appeal Process Information First-Level Appeals Appeal Process Information Regulation 7 AAC 105.270 stipulates the length of time a provider has to submit a first-level appeal. Most firstlevel appeals must be filed within 180 days

More information

TELEMEDICINE POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: January 1, 2018

TELEMEDICINE POLICY. Policy Number: ADMINISTRATIVE T0 Effective Date: January 1, 2018 TELEMEDICINE POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: ADMINISTRATIVE 114.28 T0 Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES

More information

Banner Message for the 01/30/06 ER&S and the 02/03/06 R&S Reports

Banner Message for the 01/30/06 ER&S and the 02/03/06 R&S Reports Banner Message for the 01/30/06 ER&S and the 02/03/06 R&S Reports This file contains abbreviated messages meant to provide timely notifications that affect all provider groups (physicians, dentists, and

More information

MEDIMASTER GUIDE. MediMaster Guide. Positively Aging /M.O.R.E The University of Texas Health Science Center at San Antonio

MEDIMASTER GUIDE. MediMaster Guide. Positively Aging /M.O.R.E The University of Texas Health Science Center at San Antonio MEDIMASTER GUIDE MediMaster Guide 25 Appendix: MediMaster Guide MEDICARE What is Medicare? Medicare is a hospital insurance program in the U.S. that pays for inpatient hospital care, skilled nursing facility

More information

REVISION DATE: FEBRUARY

REVISION DATE: FEBRUARY Mary Ann Hodorowicz, MBA, RDN CDE, CEC, Owner, Mary Ann Hodorowicz Consulting LLC, Palos Heights, IL Coverage: In-Person Payable Places of Services Excluded Places for Part B Payment Excluded Places: 0

More information

Section. 35Psychologist

Section. 35Psychologist Section 35Psychologist 35 35.1 Enrollment...................................................... 35-2 35.1.1 STAR and STAR+PLUS Program Enrollment.......................... 35-2 35.2 Reimbursement..................................................

More information

Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid

Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid Benefit Criteria for Outpatient Observation Services to Change for Texas Medicaid Information posted on October 8, 2010 Effective for dates of service on or after December 1, 2010, the benefit criteria

More information

Provider Handbooks. Telecommunication Services Handbook

Provider Handbooks. Telecommunication Services Handbook Provider Handbooks December 2016 Telecommunication Services Handbook The Texas Medicaid & Healthcare Partnership (TMHP) is the claims administrator for Texas Medicaid under contract with the Texas Health

More information

HealthChoice Radiology Management. March 1, 2010

HealthChoice Radiology Management. March 1, 2010 HealthChoice Radiology Management March 1, 2010 Introduction Acting on behalf of our Medicaid customers in Maryland (HealthChoice), UnitedHealthcare has worked with external physician advisory groups to

More information

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents

Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Amended Date: October 1, Table of Contents Long Term Care Hospital Clinical Coverage Policy No: 2A-2 Services (LTCH) Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 2.0 Eligibility Requirements...

More information

Telehealth. Administrative Process. Coverage. Indications that are covered

Telehealth. Administrative Process. Coverage. Indications that are covered Telehealth These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information

More information

UTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM)

UTILIZATION MANAGEMENT Section 4. Overview The Plan s Utilization Management (UM) Overview The Plan s Utilization Management (UM) Program is designed to meet contractual requirements and comply with federal regulations while providing members access to high quality, cost effective medically

More information

OUTPATIENT BEHAVIORAL HEALTH CSHCN SERVICES PROGRAM PROVIDER MANUAL

OUTPATIENT BEHAVIORAL HEALTH CSHCN SERVICES PROGRAM PROVIDER MANUAL OUTPATIENT BEHAVIORAL HEALTH CSHCN SERVICES PROGRAM PROVIDER MANUAL APRIL 2018 CSHCN PROVIDER PROCEDURES MANUAL APRIL 2018 OUTPATIENT BEHAVIORAL HEALTH Table of Contents 29.1 Enrollment......................................................................

More information

SECTION 2: TEXAS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1

SECTION 2: TEXAS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 SECTION 2: TEXAS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 DECEMBER 2017 TEXAS MEDICAID PROVIDER PROCEDURES MANUAL: VOL. 1 DECEMBER 2017 SECTION 2: TEXAS

More information

Renal Dialysis. Chapter

Renal Dialysis. Chapter Renal Dialysis Chapter.1 Enrollment..................................................................... -2.2 Client Eligibility................................................................. -2.3 Benefits,

More information

Covered Services List

Covered Services List CAREPLUS Covered Services List For CeltiCare Health with MassHealth CarePlus Coverage This is a list of all covered services and benefits for MassHealth CarePlus enrolled in CeltiCare Health. The list

More information

All Indiana Health Coverage Programs Providers. Package C Claim Submission and Coverage Information

All Indiana Health Coverage Programs Providers. Package C Claim Submission and Coverage Information P R O V I D E R B U L L E T I N B T 2 0 0 0 0 6 J A N U A R Y 2 0, 2 0 0 0 To: Subject: All Indiana Health Coverage Programs Providers Package C Claim Submission and Coverage Information Overview The purpose

More information

Account Management, Coding, Customer Service, Legal, Medical Management, Finance, Claims, Underwriting, Network Management

Account Management, Coding, Customer Service, Legal, Medical Management, Finance, Claims, Underwriting, Network Management DEPARTMENT: Coding Reimbursement APPROVED DATE: POLICY DESCRIPTION: Telemedicine/Telehealth/Telecommunications/Televideo EFFECTIVE DATE: 6-24-04 PAGE: 1 of 4 REPLACES POLICY DATED: REFERENCE NUMBER: P-30

More information

Chapter. CPT only copyright 2008 American Medical Association. All rights reserved. 30Radiation Therapy Services

Chapter. CPT only copyright 2008 American Medical Association. All rights reserved. 30Radiation Therapy Services Chapter 30Radiation Therapy Services 30 30.1 Enrollment...................................................... 30-2 30.2 Benefits, Limitations, and Authorization Requirements...................... 30-2

More information

Medicaid Program Administrator: Bureau for Medical Services, under the West Virginia Dept. of Health and Human Resources

Medicaid Program Administrator: Bureau for Medical Services, under the West Virginia Dept. of Health and Human Resources West Virginia Medicaid Program: West Virginia Medicaid Medicaid Program Administrator: Bureau for Medical Services, under the West Virginia Dept. of Health and Human Resources Regional Telehealth Resource

More information

FQHC Behavioral Health Clinical Network Retreat

FQHC Behavioral Health Clinical Network Retreat FQHC Behavioral Health Clinical Network Retreat 1 Behavioral Health Services Agenda Provider Enrollment Review Policies and Procedure Review Behavioral Health Boot Camp Questions 2 1 Disclaimer The materials

More information

Medicaid Benefits at a Glance

Medicaid Benefits at a Glance Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical

More information

Chapter. CPT only copyright 2009 American Medical Association. All rights reserved. 31Radiation Therapy Services

Chapter. CPT only copyright 2009 American Medical Association. All rights reserved. 31Radiation Therapy Services Chapter 31Radiation Therapy Services 31 31.1 Enrollment...................................................... 31-2 31.2 Benefits, Limitations, and Authorization Requirements...................... 31-2

More information

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800)

Molina Healthcare Michigan Health Care Services Department Phone: (855) Fax: (800) Utilization Management Program Molina Healthcare of Michigan s Utilization Management (UM) program utilizes a care management approach based upon empirically validated best practices, where experience

More information

Critical Care Services Benefits to Change for the CSHCN Services Program

Critical Care Services Benefits to Change for the CSHCN Services Program Critical Care Services Benefits to Change for the CSHCN Services Program Information posted July 14, 2008 Effective for dates of service on or after September 1, 2008, the benefit criteria for critical

More information

Telemedicine Policy Annual Approval Date

Telemedicine Policy Annual Approval Date Policy Number 2017R0046A Telemedicine Policy Annual Approval Date 7/13/2016 Approved By REIMBURSEMENT POLICY CMS-1500 Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You

More information

COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE

COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE This is a list of all covered services and benefits for MassHealth Standard and CommonHealth members enrolled

More information

2018 No. 5: In-Hospital Medical (Non-Surgical) Care

2018 No. 5: In-Hospital Medical (Non-Surgical) Care 2018 No. 5: In-Hospital Medical (Non-Surgical) Care POLICIES AND PROCEDURES Page 2 Table of Contents I. Daily Hospital Medical Services (New or Established Patient)... 3 II. In-Hospital Consultations...

More information

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration

Florida Medicaid. Ambulatory Surgical Center Services Coverage Policy. Agency for Health Care Administration Florida Medicaid Ambulatory Surgical Center Services Coverage Policy Agency for Health Care Administration Table of Contents 1.0 Introduction... 1 1.1 Florida Medicaid Policies..1 1.2 Statewide Medicaid

More information

MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018

MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018 MOLINA HEALTHCARE MEDICAID PRIOR AUTHORIZATION/PRE-SERVICE REVIEW GUIDE EFFECTIVE: 6/1/2018 THIS PRIOR AUTHORIZATION/PRE-SERVICE GUIDE APPLIES TO ALL MOLINA HEALTHCARE MEDICAID MEMBERS ONLY REFER TO MOLINA

More information

Telehealth and Telemedicine Policy

Telehealth and Telemedicine Policy Telehealth and Telemedicine Policy Policy Number Annual Approval Date 7/11/2018 Approved By Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare

More information

Telemedicine and Telehealth Services

Telemedicine and Telehealth Services INDIANA HEALTH COVERAGE PROGRAMS PROVIDER REFERENCE M ODULE Telemedicine and Telehealth Services L I B R A R Y R E F E R E N C E N U M B E R : P R O M O D 0 0 0 4 8 P U B L I S H E D : J A N U A R Y 1

More information

State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue.

State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue. State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 203 E. 3 rd Avenue Earl Ray Tomblin Governor Rocco S. Fucillo Cabinet Secretary November 20,

More information

KY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:

KY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant

More information

Telehealth and Telemedicine Policy

Telehealth and Telemedicine Policy Reimbursement Policy CMS 1500 Telehealth and Telemedicine Policy Policy Number 2018R0046B Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT

More information

Telehealth and Telemedicine Policy Annual Approval Date

Telehealth and Telemedicine Policy Annual Approval Date Policy Number Telehealth and Telemedicine Policy Annual Approval Date 04/12/2017 Approved By Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare

More information

KY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for

KY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant

More information

Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]

Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx] Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx] Group Plan HMO Benefit

More information

PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEDI-CAL PROVIDER MANUAL CLAIMS DEPARTMENT

PARTNERSHIP HEALTHPLAN OF CALIFORNIA MEDI-CAL PROVIDER MANUAL CLAIMS DEPARTMENT III.A. CMS 1500 Billing Form Effective April 1, 2014, the information listed below are the CMS 1500 fields that must be completed accurately and completely in order to avoid claim suspense or denial. A

More information

Core Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics

Core Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Federally Qualified Health Centers... 1

More information

Telemedicine Policy. 7/12/2017 Approved By

Telemedicine Policy. 7/12/2017 Approved By Telemedicine Policy Policy Number 2018R0046A Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission

More information

COVERED SERVICES FOR NHP MASSHEALTH MEMBERS

COVERED SERVICES FOR NHP MASSHEALTH MEMBERS COVERED SERVICES FOR NHP MASSHEALTH MEMBERS Neighborhood Health Plan Covered Services for MassHealth Standard & CommonHealth, Family Assistance, and CarePlus Issued and effective October 1, 2015 nhp.org/member

More information

Telehealth and Telemedicine Policy

Telehealth and Telemedicine Policy Reimbursement Policy CMS 1500 Telehealth and Telemedicine Policy Policy Number 2018R0046J Annual Approval Date 7/11/2018 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION... 3 SERVICES PROVIDED IN ARTICLE 28 FACILITIES... 4 MMIS MODIFIERS... 4 MEDICINE SECTION... 7 GENERAL INFORMATION

More information

MARYLAND MEDICAID TELEHEALTH PROGRAM Telehealth Provider Manual

MARYLAND MEDICAID TELEHEALTH PROGRAM Telehealth Provider Manual Telehealth Provider Manual Updated May 3, 2016 Table of Contents Table of Contents Scope Service Model Covered Services Program Eligibility Provider Registration Technical Requirements Reimbursement Confidentiality

More information

HOSPITAL CSHCN SERVICES PROGRAM PROVIDER MANUAL

HOSPITAL CSHCN SERVICES PROGRAM PROVIDER MANUAL HOSPITAL CSHCN SERVICES PROGRAM PROVIDER MANUAL JUNE 2018 CSHCN PROVIDER PROCEDURES MANUAL JUNE 2018 HOSPITAL Table of Contents 24.1 Enrollment......................................................................

More information

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES

NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION ------------------------------------------------------------------------------------------ 2 STATE DEPARTMENT

More information

WHAT DOES MEDICALLY NECESSARY MEAN?

WHAT DOES MEDICALLY NECESSARY MEAN? WHAT DOES MEDICALLY NECESSARY MEAN? Your Primary Care Provider (PCP) will help you get the services you need that are medically necessary as defined below. Medically Necessary means appropriate and necessary

More information

SECTION 14 - SPECIAL DOCUMENTATION REQUIREMENTS

SECTION 14 - SPECIAL DOCUMENTATION REQUIREMENTS SECTION 14 - SPECIAL DOCUMENTATION REQUIREMENTS 14.1 REQUIRED ATTACHMENTS...3 14.1.A RESUBMISSIONS...3 14.1.B HOW TO ORDER ATTACHMENTS...3 14.2 CERTIFICATION OF MEDICAL NECESSITY FOR ABORTION...4 14.2.A

More information

CHAPTER MA PROGRAM PAYMENT POLICIES GENERAL PROVISIONS PAYMENT FOR SERVICES

CHAPTER MA PROGRAM PAYMENT POLICIES GENERAL PROVISIONS PAYMENT FOR SERVICES Ch. 1150 MA PAYMENT POLICIES 55 CHAPTER 1150. MA PROGRAM PAYMENT POLICIES Sec. 1150.1. Policy. 1150.2. Definitions. GENERAL PROVISIONS PAYMENT FOR SERVICES 1150.51. General payment policies. 1150.52. Anesthesia

More information

Reimbursement Policy. Subject: Modifier Usage

Reimbursement Policy. Subject: Modifier Usage https://providers.amerigroup.com Reimbursement Policy Subject: Modifier Usage Effective Date:08/01/16 Committee Approval Obtained: 08/01/16 Section: Coding ***** The most current version of our reimbursement

More information

RENAL DIALYSIS CSHCN SERVICES PROGRAM PROVIDER MANUAL

RENAL DIALYSIS CSHCN SERVICES PROGRAM PROVIDER MANUAL RENAL DIALYSIS CSHCN SERVICES PROGRAM PROVIDER MANUAL JANUARY 2018 CSHCN PROVIDER PROCEDURES MANUAL JANUARY 2018 RENAL DIALYSIS Table of Contents 35.1 Enrollment......................................................................

More information

NCD for Routine Costs in Clinical Trials (310.1)

NCD for Routine Costs in Clinical Trials (310.1) NCD for Routine Costs in Clinical Trials (310.1) Publication Number 100-3 Manual Section Number 310.1 Version Number 2 Effective Date of this Version 7/9/2007 Implementation Date 10/9/2007 Benefit Category

More information

State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Oak Hill, WV 25901

State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Oak Hill, WV 25901 Earl Ray Tomblin Governor State of West Virginia DEPARTMENT OF HEALTH AND HUMAN RESOURCES Office of Inspector General Board of Review 1400 Virginia Street Oak Hill, WV 25901 Michael J. Lewis, M.D., Ph.D.

More information

Summary of Benefits Platinum Full PPO 0/10 OffEx

Summary of Benefits Platinum Full PPO 0/10 OffEx Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Full PPO 0/10 OffEx Group Plan PPO Benefit Plan This Summary of Benefits shows the amount

More information

Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000

Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Summary of Benefits Full PPO Savings Two-Tier Embedded Deductible 1500/2700/3000 Group Plan PPO Savings Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this

More information

Covered Benefits Matrix for Children

Covered Benefits Matrix for Children Medicaid Managed Care The matrix below lists the available for children (under age 21) enrolled in the West Virginia Mountain Health Trust and s. Ambulance Ambulatory surgical center services Some services

More information

Managed Care Referrals and Authorizations (Central Region Products)

Managed Care Referrals and Authorizations (Central Region Products) In this section Page Overview of Referrals and Authorizations 10.1 Referrals 10.1! Referrals: SelectBlue only 10.1! Definition of referrals 10.1! Services not requiring a referral 10.1! Who can issue a

More information

CO-PAYMENT BOOK Las Vegas Blvd. South Suite 107 Las Vegas, NV

CO-PAYMENT BOOK Las Vegas Blvd. South Suite 107 Las Vegas, NV CO-PAYMENT BOOK 1901 Las Vegas Blvd. South Suite 107 Las Vegas, NV 89104 702-733-9938 www.culinaryhealthfund.org Revised January 2018 (Replaces Co-Payment Book dated June 2017) TABLE OF CONTENTS 4 5 6

More information

Outpatient Mental Health Services

Outpatient Mental Health Services Outpatient Mental Health Services Summary of proposed changes being made to the Outpatient Mental Health Services Policy: Allow pre-doctoral psychology interns to perform psychological services when delegated

More information

See the Time chapter for complete instructions regarding how to code using time as the controlling E/M factor.

See the Time chapter for complete instructions regarding how to code using time as the controlling E/M factor. 2015 EM Survival Guides Chapter 1: Office or Other Outpatient Visit (99201-99215) You should apply 99201-99215 for E/M visits in the office or other outpatient setting. These codes distinguish between

More information

LOUISIANA MEDICAID PROGRAM ISSUED: 08/15/12 REPLACED: 07/01/11 CHAPTER 25: HOSPITAL SERVICES SECTION 25.3: OUTPATIENT SERVICES PAGE(S) 11

LOUISIANA MEDICAID PROGRAM ISSUED: 08/15/12 REPLACED: 07/01/11 CHAPTER 25: HOSPITAL SERVICES SECTION 25.3: OUTPATIENT SERVICES PAGE(S) 11 OUTPATIENT SERVICES Outpatient hospital services are defined as diagnostic and therapeutic services rendered under the direction of a physician or dentist to an outpatient in an enrolled, licensed and

More information

CHANGE M OCTOBER 23, CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2

CHANGE M OCTOBER 23, CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2 CHANGE 149 6010.58-M OCTOBER 23, 2017 REMOVE PAGE(S) INSERT PAGE(S) CHAPTER 5 Section 4, pages 1 and 2 Section 4, pages 1 and 2 CHAPTER 7 Section 2, pages 3 and 4 Section 2, pages 3 and 4 CHAPTER 13 Section

More information

Reimbursement Policy. Subject: Modifier Usage

Reimbursement Policy. Subject: Modifier Usage Reimbursement Policy Subject: Modifier Usage Effective Date: 09/15/17 Committee Approval Obtained: 08/31/17 Section: Coding ***** The most current version of our reimbursement policies can be found on

More information

OF BENEFITS. Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted

OF BENEFITS. Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted agesummary OF BENEFITS Cover erage Cigna-HealthSpring TotalCare (HMO SNP) H3949-009 2014 Cigna H3949_15_19921 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get

More information

Florida Medicaid. Evaluation and Management Services Coverage Policy

Florida Medicaid. Evaluation and Management Services Coverage Policy Florida Medicaid Evaluation and Management Services Coverage Policy Agency for Health Care Administration June 2016 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority... 1

More information

Telemedicine Policy. Approved By 4/08/2015

Telemedicine Policy. Approved By 4/08/2015 Telemedicine Policy Policy Number 2016R0046B Annual Approval Date 4/08/2015 Approved By Payment Policy Oversight Committee IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY You are responsible for submission

More information

Correction Notice. Health Partners Medicare Special Plan

Correction Notice. Health Partners Medicare Special Plan Correction Notice Special Plan Following are corrections that apply to both the English and Spanish versions of the 2015 for Special (HMO SNP): Original Information Page 1, under the heading SECTIONS IN

More information

Medical Management Program

Medical Management Program Medical Management Program Introduction Molina Healthcare maintains a medical management program to ensure patient safety as well as detect and prevent Fraud, Waste and Abuse in its programs. The Molina

More information

INTRODUCTION TO HEALTH CAREERS

INTRODUCTION TO HEALTH CAREERS INTRODUCTION TO HEALTH CAREERS C Pre-Health Advising Misty Huacuja-LaPointe, Director Abby Voss, Assistant Director Nicole Labrecque, Department Coordinator We don t just advise pre-med Agenda Exploration

More information

Texas Medicaid F00106

Texas Medicaid F00106 Texas Medicaid Provider Enrollment Application Rev. XXXVI F00106 Introduction Dear Health-Care Professional: Thank you for your interest in becoming a Texas Medicaid provider. Participation by providers

More information

Summary of Benefits Platinum Trio HMO 0/25 OffEx

Summary of Benefits Platinum Trio HMO 0/25 OffEx Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Trio HMO 0/25 OffEx Group Plan HMO Benefit Plan This Summary of Benefits shows the amount

More information

Martin s Point US Family Health Plan Pre-Authorization Requirements

Martin s Point US Family Health Plan Pre-Authorization Requirements Martin s Point US Family Health Plan Requirements Requirements described below are for covered benefits only and this information is provided for summary purposes only. Please call 1-888-732-7364 for complete

More information

UTILIZATION MANAGEMENT AND CARE COORDINATION Section 8

UTILIZATION MANAGEMENT AND CARE COORDINATION Section 8 Overview The focus of WellCare s Utilization Management (UM) Program is to provide members access to quality care and to monitor the appropriate utilization of services. WellCare s UM Program has five

More information

Eligibility. Program Structure and Process for Receiving Incentives

Eligibility. Program Structure and Process for Receiving Incentives Overview of Medicare Incentives in the Centers for Medicare & Medicaid Services (CMS) Final Rule on Meaningful Use of Certified Electronic Health Records 1 Eligibility Medicare Eligibility: For Medicare

More information

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Issue Date: August 26, 1985 Authority: 32 CFR 199.14(d) Copyright: CPT only 2006 American Medical Association (or such other date of publication of

More information

ICD-10/APR-DRG. HP Provider Relations/September 2015

ICD-10/APR-DRG. HP Provider Relations/September 2015 ICD-10/APR-DRG HP Provider Relations/September 2015 Agenda ICD-10 ICD-10 General Overview Who is affected Preparation Testing Prior Authorization APR-DRG Inpatient hospital rates Crosswalks Questions 2

More information

TRICARE Reimbursement Manual M, February 1, 2008 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1

TRICARE Reimbursement Manual M, February 1, 2008 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Ambulatory Surgical Center (ASC) Reimbursement Prior To Implementation Of Outpatient Prospective Payment (OPPS), And Thereafter, Freestanding ASCs,

More information

PREVENTIVE MEDICINE AND SCREENING POLICY

PREVENTIVE MEDICINE AND SCREENING POLICY UnitedHealthcare Oxford Reimbursement Policy PREVENTIVE MEDICINE AND SCREENING POLICY Policy Number: ADMINISTRATIVE 238.19 T0 Effective Date: July 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE...

More information

Emergency Rooms and Medical Necessity

Emergency Rooms and Medical Necessity Emergency Rooms and Medical Necessity Questions and Answers from the Health Care Authority on limiting payment for not medically necessary in the Emergency Room setting. These are questions and answers

More information

Modifiers 80, 81, 82, and AS - Assistant At Surgery

Modifiers 80, 81, 82, and AS - Assistant At Surgery Manual: Policy Title: Reimbursement Policy Modifiers 80, 81, 82, and AS - Assistant At Surgery Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM013 Last Updated: 7/11/2017

More information

Florida Medicaid. Statewide Inpatient Psychiatric Program Coverage Policy

Florida Medicaid. Statewide Inpatient Psychiatric Program Coverage Policy Florida Medicaid Statewide Inpatient Psychiatric Program Coverage Policy Agency for Health Care Administration December 2015 Table of Contents 1.0 Introduction... 1 1.1 Description... 1 1.2 Legal Authority...

More information

Florida Medicaid OPTOMETRIC SERVICES COVERAGE AND LIMITATIONS HANDBOOK

Florida Medicaid OPTOMETRIC SERVICES COVERAGE AND LIMITATIONS HANDBOOK Florida Medicaid OPTOMETRIC SERVICES COVERAGE AND LIMITATIONS HANDBOOK Agency for Health Care Administration May 2014 How to Use the Update Log OPTOMETRIC SERVICES COVERAGE AND LIMITATIONS HANDBOOK UPDATE

More information

FREEDOM BLUE PPO R CO 307 9/06. Freedom Blue PPO SM Summary of Benefits and Other Value Added Services

FREEDOM BLUE PPO R CO 307 9/06. Freedom Blue PPO SM Summary of Benefits and Other Value Added Services FREEDOM BLUE PPO R9943 2007 CO 307 9/06 Freedom Blue PPO SM Summary of Benefits and Other Value Added Services Introduction to Summary of Benefits for Freedom Blue January 1, 2007 - December 31, 2007 California

More information

Covered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice

Covered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits

More information

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement

Chapter 9 Section 1. Ambulatory Surgical Center (ASC) Reimbursement Ambulatory Surgery Centers (ASCs) Chapter 9 Section 1 Issue Date: August 26, 1985 Authority: 32 CFR 199.14(d) Copyright: CPT only 2006 American Medical Association (or such other date of publication of

More information

IPN s credentialing/recredentialing program has been certified by NCQA as of August 12, 2014.

IPN s credentialing/recredentialing program has been certified by NCQA as of August 12, 2014. Credentialing is primary source verification of a health care practitioner s education, training, work experience, license, etc. A variety of resources are used to verify the information provided by the

More information