Payment Integrity Policies
The following chart lists the policy number, policy name, a description of the policy, and applicable lines of business.
Policy Number | Policy Name | Description of policy | Line of Business |
|---|---|---|---|
CC.PP.007, effective July 5, 2019 | Maximum-units edits are unit-of-service claim edits applied to medical claims against a procedure code for medical services rendered by one provider/supplier to one patient for a period of time, usually one day. Such claim edits compare different values on medical claims to a set of defined criteria to check for irregularities. Maximum-units edits are designed to limit fraud or coding errors. They represent an upper limit beyond which requires further documentation to support. The Maximum Units of Service policy is derived from several sources: CMS, AMA CPT, knowledge of anatomy, the standards of medical practice, FDA (U.S. Food and Drug Administration) and other nationally recognized drug references, and outlier claims data from provider billing patterns. Claim lines exceeding the maximum-allowable units will be denied. | Commercial,* Medicare, Medi-Cal (including CalViva Health) | |
CC.PP.050, effective July 12, 2021 | The use of a robotic surgical device is a method of performing a surgical procedure and not a requirement of the procedure, nor one that ensures a more successful outcome if a robotic approach had not been used. The health plan will disallow reimbursement for CPT S2900 – Surgical Techniques requiring the use of a robotic surgical system. This code is billed along with a primary surgical procedure code, and is an add-on code that denotes separate reimbursement for the robotic technique. | Commercial,* Medicare, Medi-Cal (including CalViva Health) | |
HNCA.PP.053, effective July 1, 2019 | This policy outlines enhancement of the claims review process for emergency department (ED) facility and professional claims. When a claim is submitted for payment with a Level 4 (99284) or Level 5 (99285) evaluation/management (E/M) service in conjunction with a primary diagnosis generally associated with a low level of complexity or severity, the provider may receive a written notice that Health Net will require additional information to determine reimbursement. When the provider submits medical records to support its ED coding, the records will be reviewed and the claim will be paid at the level of service that is documented. The provider will receive notice and rationale if payment is made for a code(s) other than that which was/were billed. | Commercial,* Medicare, Medi-Cal (does not apply to CalViva Health) | |
CC.PP.054, effective February 21, 2022 | The purpose of this policy is to define payment criteria for consultation services. Health Net will reimburse consultation codes at the corresponding evaluation and management (E&M) visit level. The provider should bill the E&M code (other than the consultation code) that describes the service provided. Health Net will identify consultation codes 99241-99255 and crosswalk them to the more appropriate level of office visit, established patient or subsequent hospital care procedure code (see actual policy for codes). The provider will be paid according to the fee schedule for the equivalent procedure code. | Commercial* Exchange** | |
CC.PP.055, effective July 5, 2019, for Medi-Cal. Effective as of February 1, 2020, for commercial. | To ensure higher quality laboratory tests are performed in the correct setting, in-office laboratory testing will only be allowed for the CPT and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory (lab) code list included in this policy. These are tests that are needed immediately in order to manage medical emergencies or urgent conditions. To this end, specific clinical laboratory tests have been designated as appropriate to be performed in the office setting. Reimbursement for in-office laboratory procedures is limited to those codes listed in the STAT laboratory procedure code list (see the Coding and Modifier Information section in the policy). Laboratory procedures not included on the STAT lab list should be referred to an independent, contracted lab provider. Sensitive services testing can continue to be performed in the physician's office. Applies to physicians. | Commercial,* Medi-Cal (does not apply to CalViva Health) | |
CC.PP.056, effective December 27, 2018 | 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. | Commercial,* Medicare, Medi-Cal (including CalViva Health) | |
CC.PP.063, effective December 27, 2018 | 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. | Commercial,* Medicare, Medi-Cal (including CalViva Health) | |
CC.PP.068, effective February 1, 2021 | 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. | Commercial*, Medicare | |
CC.PP.069, effective February 1, 2021 | 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. | Commercial*, Medicare | |
CC.PP.070, effective July 12, 2021 | 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 & 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. | Medicare Exchange** | |
CC.PP.071, effective June 8, 2022 | Treatment room and specialty services revenue codes characterize services performed in a facility setting that are represented by a specific procedure reportable in a treatment room setting. The patient receiving these services must be registered through the hospital business office for outpatient services on a hospital campus. Treatment room services are outpatient services furnished on hospital premises which require the use of a bed and periodic monitoring for a relatively brief episode of time to carry out certain procedures. The use of the treatment room is an expected part of a minor procedure and replaces the charge for the operating room and recovery room, as patients can also recover in the treatment room. Operating rooms are procedure rooms within a sterile corridor and are used for open or major surgical procedures usually involving general anesthesia. Applies to type of bill 130x. | Commercial,* Medicare, Medi-Cal (including CalViva Health) | |
CC.PP.073, effective August 2, 2022 | Sepsis Diagnosis | The policy describes the process for pre- and post-pay review to validate correct coding on claims billed with a sepsis diagnosis but is not applicable to sepsis screening. Acute care hospitalizations for sepsis require the most appropriate and most specific level of diagnosis coding. The medical record documentation supporting the diagnosis should be clearly documented by the physician or a licensed independent practitioner, and consistent with current guidelines. | Commercial*, Medicare, Medi-Cal (including CalViva Health) |
CC.PP.074, effective July 1, 2023 | Optum CPI ensures that claims process and pay accurately. This may result in a claim denial with a request for medical records from the provider or supplier who submitted the claim to support the services submitted on the claim. After medical records are reviewed, the claim is processed to pay if the documentation supports the claim as billed. | Medicare | |
CC.PP.500 | The health plan is adopting a reimbursement policy that is based, in large part, on the Medicare requirements for payment of outpatient diagnostic and related non-diagnostic services within the three-day (or, with respect to non-Inpatient Prospective Payment System [non-IPPS] hospitals, the one-day) window prior to and including the date of member’s inpatient admission. All hospitals, other than non-IPPS hospitals, are subject to a three-day bundling requirement when they furnish preadmission diagnostic services to a member on the date of the inpatient admission or within the three calendar days prior to the date of the inpatient admission, or when they furnish preadmission non-diagnostic services that are related to the member’s inpatient admission, on the date of the inpatient admission or within three calendar days prior to the date of the inpatient admission. All non-IPPS hospitals are subject to the one-day bundling requirement when they furnish preadmission diagnostic services to a member on the day of the inpatient admission or within the one calendar day prior to the date of the inpatient admission, or when they furnish preadmission non-diagnostic services that are related to the member’s inpatient admission, on the date of the inpatient admission or within one calendar day prior to the date of the inpatient admission. Outpatient diagnostic services and related non-diagnostic services provided to a member by a hospital on the date of an inpatient admission or within three days (or with respect a non-IPPS hospital, one day) prior to the date of the inpatient admission are deemed to be inpatient services and must be bundled on the admitting hospital’s claim for the member’s inpatient stay at the admitting hospital. Diagnostic services and related non-diagnostic services billed on outpatient bill types will be denied when the line-item date of service (LIDOS) falls on the day of admission or any of the three days (or with respect to a non-IPPS hospital, the one day) immediately prior to the date of the admission. The application of this policy will be customized for provider contract language | Commercial*, Medicare, Medi-Cal (does not apply to CalViva Health) | |
CC.PP.501, effective as of November 1, 2019 | This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission. Notwithstanding medical necessity where it is determined to exist, for a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth in the policy, the health plan will deny payment or reimbursement. A readmission will be considered to be inappropriate or preventable under ANY of the following circumstances:
The following readmissions are excluded from 30-day readmission review:
Note: The health plan will customize the application of this payment policy to accommodate specific provider contract language. | Commercial,* Medicare, Medi-Cal (does not apply to CalViva Health) | |
CP.MP.209, effective as of February 21, 2022 | Restricts reimbursement of GI pathogen panels with 12+ targets to only inpatient settings, including inpatient, ED, and outpatient hospitals. | Commercial,* Exchange** Medi-Cal (including CalViva Health) | |
CP.PHAR.176, effective February 14, 2020 | This policy advises that Abraxane is medically necessary when the criteria described in the policy are met. The purpose of this clinical policy is to provide a guide to medical necessity, which is a component of the guidelines used to assist in making coverage decisions and administering benefits. Payment for claims submitted outside of these medically necessary guidelines will be denied. Please see the CPT and ICD-10 coding guidelines documented in the policy. The applicable claims edit will be applied to claims for dates of service after February 14, 2020. | Commercial,* Medicare, Medi-Cal (does not apply to CalViva Health) |
*Commercial includes HMO, POS, HSP, PPO, EPO and products offered through Covered California. **Ambetter HMO and Ambetter PPO