Updated Payment Policies
Date: 01/20/21
Arizona Complete Health (AzCH) is publishing its Payment Policies to inform you about desired billing practices and application of reimbursement methodologies for certain procedures and services. AzCH applies these policies through medical claims reimbursement edits within our claims adjudication system along with other established reimbursement processes.
AzCH publishes this information to assist you in billing claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payment. These policies address coding inaccuracies including
- Diagnosis to procedure code mismatch
- Inappropriately modified procedures
- Unbundling
- Incidental procedures
- Duplication of services
- Medical necessity requirements
- Health plan specific payment rules for procedures and services.
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), public domain specialty society guidance, and/or also may be specifically addressed in the fee-for-service provider manual published by AHCCCS.
Visit https://www.azcompletehealth.com/providers/resources/clinical-payment-policies.html to find the Payment Policies. This communication originally sent out to the network on June 30, 2020 via communication update 20-329. The effective date for the policies was August 1, 2020. This is a reminder to review the below policies.
Number | Policy Name | Policy Description | Line of Business (LOB) |
|---|---|---|---|
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. | Medicaid |
CC.PP.066 | Leveling of Care: Evaluation & Management Overcoding | The purpose of this policy is to ensure that the level of E&M service reported by the provider reflects the services performed. When a provider submits an E&M service that exceeds the maximum level of E&M service based on the diagnosis and other claim documentation elements, the E&M code is leveled to reflect the maximum level of E&M service. | Medicare |
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, same-day screening of drug metabolites in both blood and urine specimen, or specimen validity/adulteration testing. | Marketplace |
CC.PP.054 | Physician’s Consultations Services | The purpose of this policy is to define payment criteria for consultation services to be used in making payment decisions and administering benefits. | Medicaid Medicare Marketplace |
CC.PP.052 | Problem Oriented Visits with Surgical Procedures | 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. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures | Medicaid
|
CC.PP.100 | Allergy Testing | 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. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. | Medicare |
CP.MP.149 | PROM | 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. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. | Marketplace |
CP.MP.038 | Ultrasound in Pregnancy | 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. It does not constitute a contract or guarantee regarding payment or results. Coverage decisions and the administration of benefits are subject to all terms, conditions, exclusions and limitations of the coverage documents (e.g., evidence of coverage, certificate of coverage, policy, contract of insurance, etc.), as well as to state and federal requirements and applicable Health Plan-level administrative policies and procedures. | Marketplace |