Payment Policy Change Effective 8/01/2023

Date: 06/06/23

Managed Health Services (MHS) is publishing its payment policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. MHS believes that publishing this information will help providers to bill claims more efficiently, therefore reducing unnecessary denials and delays in claims processing and payments.

We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that MHS currently employs. These policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state or MHS regulations.

We continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you that the below policies have been revised or changed.

For detailed information about these policies, please refer to our website at mhsindiana.com. For questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-877-647-4848.

Policy Name	Description/Changes	Non-adherence Consequence	Products Impacted
Inappropriate Primary Diagnosis	Deny or limit diagnosis codes based upon correct coding guidelines that are supported by CMS and ICD-10. Based on these guidelines, claims will deny when billed with unacceptable primary/principal diagnosis, manifestation diagnosis, and sequela diagnosis in outpatient or inpatient facilities.	Ex Codes: ExKi/ExcU- Inappropriate Dx Code Billed in Primary Position	Medicaid Medicare Marketplace