21-868 New and Updated Payment Policies

Date: 12/16/21

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.

Stay current on claims reimbursement and code edits to make sure your claims submission is compliant

Claims received for payment are subject to editing to make sure the claim complies with the Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) and the ICD-10-CM Official Guidelines for Coding and Reporting and other billing guidelines. Participating providers need to adhere to national billing standards and payment policies to avoid denial of claims.

New payment policies

Effective February 21, 2022, Health Net will have new or revised payment policies for:

• Physician’s Consultation Services (revised).
• 340B Drug Payment Reduction.
• Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing.

Refer to the table below for a description of the policies. Easily access policies in the Provider Library

1. Go to the Provider Library.
2. Select a line of business, then go to Provider Manual > Claims Coding Policies and select Payment Integrity Policies for the respective policy.

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.

Payment Integrity Policies

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.054	Physician’s Consultation Services	The purpose of this policy update is to ensure providers bill the correct level of evaluation and management (E&M) CPT® codes when billing for physician’s consultation services. Furthermore this is to encourage providers to bill consultation services based on 1) where the visit occurred and, 2) the complexity of the visit performed. Instead of denying such consultation codes if billed, as originally outlined in Provider Update 10-073 sent on February 26, 2010, they will be reimbursed at the corresponding E&M visit level. The provider should bill the E&M code (other than the consultation code) that describes the service provided.	Physicians and participating physician groups	Commercial* Exchange**
CC.PP.070	340B Drug Payment Reduction	The purpose of this policy is to ensure that providers participating in the 340B Drug Pricing Program are correctly reporting 340B acquired drugs according to guidelines established by the Centers for Medicare and Medicaid Services (CMS). CMS reduces payment to participating providers paid under an Outpatient Prospective Payment System (OPPS) for specific drugs acquired through the 340B program. Providers are required to report either modifier “JG” or “TB” on these claims. Modifier “TB’ is reported for informational purposes. Modifier “JG” indicates the 340B drug is payable at a reduced rate of Average Sales Price (ASP) minus 22.5 percent. This editing may be applied pre-payment or post-payment.	Physicians, participating physician groups, hospitals and ancillary providers	Exchange**
CP.MP.209	Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing	Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, emergency department, and outpatient hospitals.	Physicians, participating physician groups, hospitals and ancillary providers	Commercial* Exchange** Medi-Cal

*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California.
**EnhancedCare PPO, CommunityCare HMO, PureCare HSP and Purecare One EPO

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 Portal > Provider Library  > Quick Links.

If you have questions regarding the information contained in this update, contact the Health Net Provider Services Center within 60 days, by phone or through the provider website as listed below.

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