23-015 Bill Correctly to Get Paid for Pulmonary Testing and Skin Substitute Claims
Date: 01/05/23
New payment policy edits and post-payment edits follow national guidelines
Effective March 15, 2023, California Health & Wellness Plan (CHWP) will implement new edits described below on claim payments to ensure compliance with company standards and national billing guidelines.
Pulmonary function testing claims
CHWP will apply edits to ensure medical necessity guidelines are met for payment. For more information, refer to the policy, CP.MP.242, Clinical Policy: Pulmonary Function Testing (PDF).
Skin substitute claims
CHWP will implement retrospective payment edits for skin substitute correct billing review. Claims coding edits align with Medi-Cal and Centers for Medicare & Medicaid Services (CMS) policy guidelines or manuals.
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- Medi-Cal coding guidelines: Reimbursable only when billed in conjunction with an application CPT code in the range of 15271 through 15278.
Additional information
Providers are encouraged to access CHWP’s provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CHWP at 877-658-0305.
This Information applies to Physicians, Hospitals, Ancillary providers, Independent Practice Associations (IPAs), Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.