Payment Policy Changes
Date: 10/26/23
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 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.
Visit mhsindiana.com to find the Payment Policies. The effective date for the below policy revisions is July 15, 2023.
Policy Name | Description | Non-adherence Consequence | Products Impacted |
|---|---|---|---|
CP.MP.100 | Policy is being retired. |
| Medicaid |
CP.MP.100 | Change codes 86160, 86161 and 86162 from not payable to NOT payable only when billed with the following diagnosis codes:, B44.81, H10.01* through H10.45, J30.1 through J30.9, J30.0, J31.0, J45.2* through J45.998 , L20.84 , L20.89, L20.9, L23.0 through L23.9*, L25.1 through L25.9, L27.0 through L27.9 , L50.0, L50.1, L50.6, L50.8, L50.9, L56.1, L56.2, L56.3, R06.2, T36.0X5A through T50.995S , T63.001* - T63.94*, T78.00X* through T78.1XXS, T78.49XA through T78.49XS , T80.52XA through T80.52XS, T88.6XXA through T88.6XXS , Z88.0 through Z88.9, Z91.010 through Z91.018,
Add the following diagnosis codes as payable with 86003, 86005, 86008, 95004, 95017, 95018, 95024, 95027 and 95028. L20.0, L20.81-L20.83, L24.9, L30.2.
Add CPT 86001 as NOT payable. | xE/yE- PROCEDURE CODE IS DISALLOWED WITH THIS DIAGNOSIS CODE(S) PER PLAN POLICY | Marketplace |
CP.MP.97 Testing for Select Genitourinary Conditions | Policy is being retired |
| Medicaid |
CP.MP.97 Testing for Select Genitourinary Conditions
| Added 0330U and 0352U as not med nec for members over age 13 (new code for July '22 with no utilization/cost data).
Changed matching requirements for ICD-10 B37.3 to apply to B37.31 and B37.32 which together now replace B37.3.
Changed CPT 87481 from not medically necessary in any circumstance to not med nec when paired with the following dx codes, and only applied to members 13 years and over. Required the same dx code matching for new code 0353U (with no utilization/cost data): B37.31, B37.32, L29.2, L29.3, N39.0,N72, N76.0, N76.1, N76.2, N76.3, N76.81, N76.89, N77.1, N89.8, N89.9, N90.89, N90.9, N91.0 –N91.5, N92.0, N93.0, N93.8, N93.9, N94.3, N94.4 – N94.6, N94.89, N94.9, O09.00-O09.03, O09.10-O09.13, O09.A0-O09.A3, O09.211-O09. 219,O09. 291-O09. 299,O09.30-O09.33,O09. 40-O09.43, O09.511-O09.519, O09.521- O09. 529, O09.611-O09.619, O09.621-O09.629, O09.70-O09.73, O09.811-O09.819, O09.821-O09.829, O09.891-O09.899, O09.90-O09.93, O23.511– O23.93, Z00.00,Z00.8,Z01.419,Z11.3,Z11.51,Z22.330,Z23,Z30.011 – Z30.019,Z30.02, Z30.09,Z30.40 – Z30.9,Z32.00, Z33.1, Z34.00 – Z34.03, Z34.80 – Z34.83, Z34.90 – Z34.93, Z36.0-Z36.5, Z36.81-Z36.9, Z38.00 – Z38.01, Z38.30 – Z38.31, Z38.61 – Z38.69, Z39.0 – Z39.2, Z3A.00 – Z3A.49, Z72.51 – Z72.53, Z86.19, Z97.5 | Yw- NOT MEDICALLY NECESSARY OR INELIGIBLE SERVICE PER CMS OR PLAN RULES | Medicare |
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 MHS Provider Services at 1-877-647-4848.