Provider Update: Payment Integrity Policies Changes
Date: 08/16/19
This update applies to Trillium Oregon Health Plan (OHP) and Medicare Advantage plans.
Trillium Community Health Plan (Trillium) is publishing its Payment Policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. 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 Trillium currently employs.
Trillium believes that publishing this information will help providers to bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments. These policies address coding inaccuracies including diagnosis to procedure code mismatch, inappropriately modified procedures, unbundling, incidental procedures, duplication of services, medical necessity requirements, and health plan specific payment rules for procedures and services.
The effective date for these policies listed below is October 1, 2019. These policies apply to all Trillium products, unless otherwise noted.
To view policies online, visit the Trillium provider website at trilliumohp.com/providers/helpful-links/clinical-payment-policies.
Payment Policies
Policy Reference Number | Policy Name | Description |
|---|---|---|
Physician's Office Lab Testing | To ensure higher quality laboratory tests are performed in the correct setting, the health plan will limit the performance of in-office laboratory testing to the CPT® and HCPCS codes listed in the Short Turnaround Time (STAT) laboratory (lab) code list included in this policy. The purpose of this policy is to define payment criteria for in-office laboratory procedures to be used in making payment decisions and administering benefits. Furthermore to encourage the specialization of independent labs to ensure higher quality laboratory tests are performed in the appropriate setting. | |
Problem Oriented Visits Billed with Surgical Procedures | Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented evaluation and management (E&M) service on the same day of a procedure with a 0-, 10- or 90- day global surgical period if the physician indicates that the service is a significant and separately identifiable E&M service that is above and beyond the usual pre- and post-operative work associated with the procedure. The purpose of this policy is to prevent duplicate payments that occur when a provider is reimbursed for resources not directly consumed during the provision of a service. Furthermore, to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure with a 0-, 10- or 90- day global period when making payment decisions and administering benefits. | |
EpiFix Wound Treatment | EpiFix® (MiMedx Group) is dehydrated human amniotic tissue that is used as an allograft material (or tissue graft) to treat nonhealing wounds. It is the policy of health plans affiliated with Centene Corporation® that Epifix is medically necessary for the treatment of chronic foot ulcers when all criteria are met. It is the policy of health plans affiliated with Centene Corporation that continued treatment with EpiFix is not medically necessary when the ulcer fails to heal by ≥ 50% within the first 6 weeks of treatment. Treatment beyond 12 weeks is considered not medically necessary regardless of wound status. | |
Status P Bundled Services | The Centers for Medicare and Medicaid Services (CMS) classifies certain procedure codes as always bundled when billed on the same claim or a historical claim containing another procedure code or codes to which the bundled code shares an incidental relationship. The purpose of this policy is to define payment criteria for covered services designated by CMS as always bundled to another physician’s procedure or service to be used in making payment decisions and administering benefits. | |
Allergy Testing | Allergy testing is performed to determine immunologic sensitivity or reaction to antigens for the purpose of identifying the cause of the allergic state. This policy addresses immediate (IgE-mediated) hypersensitivity and delayed (cell-mediated) hypersensitivity. Allergen immunotherapy is the repeated administration of specific allergens to patients with IgE-mediated conditions, for the purpose of providing protection against the allergic symptoms and inflammatory reactions associated with exposure to these allergens. Please note: unit limitations for allergy testing and treatment are based on state specific guidelines (defined in the provider fee schedule). In the absence of state-specific rules, the CMS Medicaid/Medicare NCCI MUE limitations are applied. | |
Urodynamic Testing | Urodynamic testing is an important part of the comprehensive evaluation of voiding dysfunction. The clinician must exercise clinical judgment in the appropriate selection of urodynamic tests following an appropriate evaluation and symptom characterization. The purpose of this policy is to define medical necessity criteria for commonly used urodynamic studies. | |
Leveling of Emergency Room Services | 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 Trillium 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. |