20-910 New Payment Policies and Reminder on Correct Coding Guidelines

Date: 11/16/20

This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.

For Medi-Cal, this information applies to Kern, Los Angeles, Riverside, Sacramento, San Bernardino, San Diego, San Joaquin, Stanislaus, and Tulare counties.

Refer to information about reimbursement changes for multiple therapeutic and ophthalmology services and make sure your claims submission is compliant

Effective February 1, 2021, Health Net is implementing two new payment policies.

These policies describe a reimbursement change for multiple Therapeutic and Ophthalmology services performed on the same day, by the same provider, on the same patient. We have also included an important reminder regarding authorization and correct code editing.

Refer to the table below for a description of the policies.

Correct coding guidelines (all providers)

All claims submitted for payment are subject to editing to ensure the claim complies with National Correct Coding Guidelines and the ICD-10-CM Official Guidelines for Coding and Reporting. If your claim is denied, you will need to resubmit a corrected claim following the National and ICD-10 coding guidelines.

These guidelines have been approved by the four organizations that make up the Cooperating Parties for the ICD-10-CM:

• The American Hospital Association (AHA)
• The American Health Information Management Association (AHIMA)
• Centers for Medicare & Medicaid Services (CMS)
• National Center for Health Statistics (NCHS)

Editing for correct coding

Editing for correct coding does not in any way modify or rescind an authorization for services, nor does this have any impact on the medical necessity determination of that service.

Access new policies easily

Use one of the two options below to view policies in the Provider Library.

Option 1 – Log on to the provider website

If you are serving members enrolled in:

• Individual Medicare Advantage (MA)
• Individual Family Plan (IFP)

Go to...

1. The Health Net California Provider Portal.
2. Select Working with Health Net > Contractual > Policy Library > Go to the Provider Library.
3. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.

If you are serving members enrolled in:

• Employer group HMO, Point of Service (POS), HSP, PPO and EPO
• MA employer group
• Medi-Cal

Go to...

1. The Health Net Provider Portal.
2. Select Working with Health Net > Contractual > Policy Library > Go to the Provider Library.
3. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.

Option 2 – Go directly to the Provider Library

1. Go to the Health Net California Provider Library.
2. Once in the Provider Library, select a line of business, then go to Provider Manual > Claims Coding Policies and select Clinical Payment Policies or Payment Integrity Policies for the respective policy.

Policy chart

The following chart lists the policy number, policy name, a description of the policy, applicable providers and applicable lines of business.

Policy number	Policy name	Description of policy	Providers	Lines of business
CC.PP.068	Multiple Procedure Payment Reduction (MPPR) for Therapeutic Services	This policy is based on Centers for Medicare & Medicaid Services (CMS) reimbursement methodologies for MPPR and applies a multiple procedure payment reduction to therapeutic procedures assigned a multiple procedure indicator (MPI) of 5 on the CMS National Physician Fee Schedule (NPFS). When multiple procedures/units are billed, for the same patient, full payment (100%) is made for the unit or procedure with the highest value and payment for subsequent procedures/units is reimbursed at 90% of the allowance. This reduction applies to all therapy services furnished on the same day, by the same provider, regardless of whether the services were provided in one therapy discipline or multiple disciplines, such as physical therapy, occupational therapy, or speech-language pathology.	Physicians, participating physician groups, hospitals and ancillary providers	Commercial*, Medicare,
CC.PP.069	Multiple Procedure Reduction: Ophthalmology	This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple procedure reimbursement reduction to diagnostic ophthalmology procedures assigned a Multiple procedure indicator (MPI) of 7 on the CMS National Physician Fee Schedule (NPFS). When multiple (two or more) diagnostic ophthalmology procedures with an MPI of 7 are performed by the same provider, on the same patient, on the same day, we will allow 100% of the maximum allowance for the first diagnostic procedure with the highest cost per unit and 80% of the allowance for each subsequent diagnostic ophthalmology procedure.	Physicians, participating physician groups, hospitals and ancillary providers	Commercial*, Medicare,

*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California.

Claims Reimbursement for Contracted Providers

Health Net’s reimbursement to contracted providers for covered services is based on specific negotiated contract provisions supplemented by the contents of disclosed and consistent fee schedules, payment policies and coding methodologies.

Additional information

Relevant sections of Health Net’s provider operations manuals have been revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net’s provider website as listed below.

If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:

Line of Business	Telephone Number	Provider Portal	Email Address
EnhancedCare PPO (IFP)	1-844-463-8188	Health Net California Provider Portal	provider_services@healthnet.com
EnhancedCare PPO (SBG)	1-844-463-8188	Health Net Provider Portal	provider_services@healthnet.com
Health Net Employer Group HMO, POS, HSP, PPO, & EPO	1-800-641-7761	Health Net Provider Portal	provider_services@healthnet.com
IFP (CommunityCare HMO, PPO, PureCare HSP, PureCare One EPO)	1-888-926-2164	Health Net California Provider Portal	provider_services@healthnet.com
Medicare (individual)	1-800-929-9224	Health Net California Provider Portal	provider_services@healthnet.com
Medicare (employer group)	1-800-929-9224	Health Net Provider Portal	provider_services@healthnet.com
Medi-Cal	1-800-675-6110	Health Net Provider Portal	N/A