23-014 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, Health Net*, on behalf of CalViva Health, will implement new edits described below on claim payments to ensure compliance with company standards and national billing guidelines.
Pulmonary function testing claims
The Plan 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
The Plan 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 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.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, Ancillary providers, Community Supports (CS) Providers, and Enhanced Care Management (ECM) Providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.