News
Updated Payment Policies
Date: 11/04/20
Effective 01/01/2021
Ambetter of North Carolina is implementing Payment & Clinical Policies that will guide how claims for certain services are adjudicated and paid. We will be instituting these policies to provide clinically based rule content to evaluate claims against payment and clinical policies to ensure accurate reimbursement. This is in addition to all other reimbursement processes that Ambetter of North Carolina Inc. currently employs. The policies that dictate the coding and billing rules applied are based on industry standards and guidelines as published and defined in the Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society edits, unless specifically by the State of North Carolina regulations. These policies apply to all Ambetter of North Carolina Inc. products, unless otherwise noted.
The effective date for the policies below is 1/1/2021. These policies apply to all Ambetter of North Carolina products unless otherwise noted.
The policies can be found on Ambetter of North Carolina Inc.’s web site.
| Policy Number | Policy Name | Policy Description | Lines of Business |
|---|---|---|---|
| CC.PP.065 | Multiple Diagnostic Cardiovascular Procedure Payment Reduction | This policy is based on CMS reimbursement methodologies for MPPR and applies a multiple diagnostic cardiovascular procedure reimbursement reduction (MDCR) to procedures assigned a multiple procedure indicator (MPI) of 6 on the CMS National Physician Fee Schedule (NPFS). When this occurs, only the highest-valued procedure is reimbursed at the full payment allowance (100%) and payment for subsequent procedures/units is reimbursed at 75% of the allowance | Marketplace |
| CC.MP.50 | Outpatient Testing for Drugs of Abuse | For members over the age of 6, outpatient testing for drugs of abuse is medically necessary when certain criteria is met (see below). Outpatient quantitative drug testing of more than 14 drugs/drug classes is NOT medically necessary. Urine drug testing is considered NOT medically necessary for reasons including, but not limited to, a condition of employment or participation in a school activity, court-ordered drug screenings, screening in asymptomatic patients (except what is outlined below), a component of a routine physical, sameday screening of drug metabolites in both blood and urine specimen, or specimen validity/adulteration testing | Marketplace |
| CP.MP.181 | Polymerase Chain Reaction Respiratory Viral Panel Testing | Respiratory viral panels (RVPs) testing for 3-5 targets is considered medically necessary when performed in the outpatient setting and meeting the specific diagnostic requirements outlined in the policy or when performed in a healthcare setting that cares for critically ill patients. RVPs testing for six pathogens or more are only considered medically necessary when performed in healthcare settings that cares for critically ill patients, such as the emergency department or inpatient hospital, including those in observation status. | Marketplace |
| CC.PP.069 | Multiple Procedure Reduction: Ophthalmology | 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, the policy 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 unless the modifier -26 is present. | Marketplace |
| CC.PP.068 | Multiple Procedure Payment Reduction for Therapeutic Services | When multiple (two or more) ‘always therapy’ procedures with an MPI of 5 are performed by the same provider, or by providers within the same group practice, on the same day, the policy will allow 100% of the maximum allowance for the therapeutic procedure with the highest cost per until and 90% of the allowance for each subsequent therapeutic procedure | Marketplace |
| CC.PP.061 | Non-OB & OB Transabdominal and Transvaginal Ultrasounds | Revision to the existing CC.PP.061 policy to include a multi-procedure reduction for transvaginal and 1st-trimester abdominal ultrasound performed on the same day. The transvaginal ultrasound would be paid at 100% and the abdominal ultrasound will be reduced by 50%. | Marketplace |