21-870 New and Updated Payment Policies
Date: 12/16/21
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera 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 policy
Effective February 21, 2022, Health Net on behalf of CalViva Health, will have a new payment policy for:
- Gastrointestinal Pathogen Nucleic Acid Detection Panel Testing.
Refer to the table below for a description of the policy.
Easily access policies in the Provider Library
- Go to the Provider Library.
- 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
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 Policy
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 |
|---|---|---|---|---|
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 | Medi-Cal |
Additional information
Relevant sections of the 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.
Providers are encouraged to access the 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 CalViva Health at 888-893-1569.