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Implementation of New Payment Integrity Policies

Date: 10/22/18

Policies effective as of December 27, 2018

In order to improve affordability for our members and to encourage appropriate utilization of resources and the highest quality of treatment, California Health & Wellness Plan (CHWP) is implementing two new policies effective December 27, 2018. These policies follow the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines and will impact providers who are coding outside of fair and appropriate use.

These policies outline acceptable billing practices and reimbursement methodologies for certain procedures and services, and are developed based on medical literature and research, and industry standards and guidelines as published and defined by the American Medical Association’s (AMA’s) CPT,® CMS and public domain specialty society guidance, unless specifically addressed in the Medi-Cal fee-for-service provider manual published by California. The information included in these policies will help providers bill claims accurately, therefore reducing unnecessary denials and delays in claims processing and payments. These policies include information on:

·    Coding inaccuracies

·    Diagnosis to procedure code mismatch

·    Inappropriately modified procedures

·    Unbundling of services

·    Incidental procedures

·    Duplication of services

·    Medical necessity requirements

·    Health plan-specific payment rules for procedures and services

The table on page 2 includes a list of the new policies, including the policy number, policy title, a brief description, and impacted line of business.

APPLICATION OF CLAIMS POLICIES

CHWP will apply these policies as medical claims reimbursement edits within our claims adjudication system, in addition to all other reimbursement processes CHWP currently employs.

PAYMENT INTEGRITY POLICIES

Policy Number

Policy

Policy Description

Line of Business

CC.PP.056

Payment Policy: Urine Specimen Validity Testing

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Adulteration testing is the tampering or manipulation of a urine specimen with the intention of altering the test results. This tampering can cause false negative results by destroying drugs present in the urine sample and/or interfering with drug screening results.

Medi-Cal

CC.PP.063

Transparency Policy: Place of Service Mismatch

The purpose of this policy is to identify instances in which a procedure code is billed with an inappropriate place of service per CPT/HCPCS guidelines. For some CPT and HCPCS codes, criteria are included for where these services may be performed. According to the CPT manual, place of service (POS) should be specified and match the procedure code’s description and/or guidelines for use. The edit takes AMA, CMS and state guidelines into consideration to ensure accurate reimbursement for services provided within each individual health plan.

Medi-Cal


ADDITIONAL INFORMATION

CHWP Clinical & Payment policies can be accessed online at:

https://www.cahealthwellness.com/providers/resources/clinical-payment-policies.html

If you have questions regarding the information contained in this update, contact your Provider Relations representative or call 1-877-658-0305.