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Payment Integrity Policies

Date: 03/27/18

Health Net Oregon 18-008

In order to improve affordability for our members, promote appropriate utilization of resources, and encourage the highest quality treatment, Health Net Health Plan of Oregon, Inc. and Health Net Life Insurance, Inc. (Health Net) are implementing eight new policies across all lines of business, effective June 1, 2018. The policies follow Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) guidelines and will likely impact only a small number of providers who may be coding outside of fair and appropriate use.

The table on page 2 summarizes each policy and applicable lines of business.

Background

To inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services, Health Net is publishing payment policies. Health Net will apply these policies as medical claims reimbursement edits within Health Net's claims adjudication system, in addition to all other reimbursement processes Health Net currently employs.

This information will help providers bill claims accurately, 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.

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®), CMS and public domain specialty society guidance, unless specifically addressed in the fee-for-service provider manual published by the state of Oregon or regulations.

The effective date of the below policies is June 1, 2018.

To view policies online, visit the Health Net provider website at provider.healthnet.com under Working with Health Net > Contractual > Policy Library > Go to the Provider Library. Once in the Provider Library, go to Operations Manuals > Claims Coding Policies or search using keywords.

Additional Information

Relevant sections of Health Net's provider operations manuals will be revised to reflect the information contained in this update as applicable. Provider operations manuals are available electronically in the Provider Library, located on Health Net's provider website at provider.healthnet.com.

Providers are encouraged to access Health Net's provider portal online, as listed in the table below, for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.

If you have questions regarding the information contained in this update, contact the applicable Health Net Provider Services Center within 60 days at:

Line of Business

Telephone Number

Provider Portal

Medicare Advantage

1-888-445-8913

provider.healthnetoregon.com

EPO, POS, PPO, & CommunityCare

1-888-802-7001

provider.healthnet.com

Payment Integrity Policies

Policy Reference Number

Policy Name

Line of Business

Description

CC.PI.04

Equian for Clean Claim Reviews

All

The purpose of this policy is to define the referral criteria, review components, and guidelines used to support the inpatient clean claim reviews.

Criteria for high-dollar clean claim review includes, but is not limited to, pre-payment, inpatient claims greater than $50,000 payable for Medicare for inpatient claims that hit DRG outlier. These reviews will also be applied to claims paying on a percentage of billed charges methodology, payable greater than $50,000.

CP.PP.052

Problem Oriented Visits with Surgical Procedures

All

The purpose of this policy is to define payment criteria for problem-oriented visits when billed on the same day as a surgical procedure to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for a problem-oriented E&M service on the same day of a procedure with a 0-, 10- or 90-day global surgical period.

Providers do not incur duplicate indirect expenses with the problem-oriented E&M service when there is a surgical procedure on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the surgical procedure plus 50 percent of the problem-oriented E&M code.

CC.PP.055

Physician's Office Lab Testing

All

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.

Health Net reimbursement for in-office laboratory procedures is limited to those codes listed in the STAT laboratory procedure code list (see the Coding and Modifier Information section). Laboratory procedures not included on the STAT lab list may not be performed in the office and should be referred to an independent, contracted lab provider.

CC.PP.056

Urine Specimen Validity Testing

All

The purpose of this policy is to define payment criteria for urine specimen validity testing to be used in making payment decisions and administering benefits.

Health Net will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated. Validity testing in an internal control process that is not separately reportable.

CC.PP.057

Problem Oriented Visits with Preventive Visits

All

The purpose of this policy is to define payment criteria for problem-oriented visits when billed with preventive visits to be used in making payment decisions and administering benefits.

Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventive E&M service and a problem-oriented E&M service during the same patient encounter.

Providers do not incur duplicate indirect expenses with the original E&M (preventive service) when there is a problem-oriented visit on the same date of service. For example, obtaining vital signs, scheduling the visits, staffing, lighting, and supplying the examination room costs are not incurred twice by the provider. Health Net will reimburse the preventive medicine code plus 50 percent of the problem-oriented E&M code.

CP.MP.149

Non-invasive Testing for Rupture of Fetal Membranes

All

The purpose of this policy is to define medical necessity criteria for the non-invasive testing for rupture of fetal membranes testing (e.g. AmniSure®, Actim® PROM and the ROM Plus Fetal Membranes Rupture Test) for the diagnostic evaluation of premature rupture of membranes.

CC.PP.500

3-day Payment Window

All

The purpose of this policy is to serve as one component of the guidelines used to assist in making coverage decisions and administering benefits. 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.), and to applicable law.

CC.PP.501

30 Day Readmission

All

This policy is based, in part, on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

For a readmission that is determined to have been inappropriate or preventable according to the clinical review guidelines set forth below, Health Net will deny payment or reimbursement.

Biopharmaceutical Clinical Decision

Health Net is changing the authorization setup for the following four drugs to require authorization for all providers. In many states, these drugs do not require authorization for hospitals, hematologists, oncologists, and neurologists. This change is being implemented to ensure these drugs are being utilized according to NCCN (National Comprehensive Cancer Network®) guidelines. Requests for these drugs will be reviewed using previously established medical necessity criteria.

  • Brentuximab - J9042
  • Pembrolizumab - J9271
  • Nivolumab - J9299
  • Pertuzumab - J9306

Code Auditing

Health Net uses code auditing software to improve accuracy and efficiency in claims processing, payment, and reporting. The software detects and documents coding errors on provider claims prior to payment by analyzing CPT, HCPCS, ICD-10, modifier and place of service codes against correct coding guidelines.

Each rule within the software is linked to a generally accepted coding principle. Guidance surrounding the most likely clinical scenario is applied. This information is provided by clinical consultants, health plan medical directors, current research, etc. The following sources are utilized in determining correct coding guidelines for the software:

  • Centers for Medicare & Medicaid Services (including NCCI, MUE, and Claims Processing Manual guidelines)
  • American Medical Association (CPT, HCPCS, and ICD-10 publications)
  • Public domain specialty provider associations (such as American College of Surgeons, American Academy of Orthopaedic Surgeons, etc.)
  • State provider manuals and fee schedules
  • Clinical consultants who research, document, and provide edit recommendations based on the most common clinical scenario
  • Health plan policies and provider contract considerations
  • In addition to nationally-recognized coding guidelines, the software has flexibility to allow business rules that are unique to the needs of individual product lines

While code auditing software is a useful tool to ensure provider compliance with correct coding, it will not wholly evaluate all clinical patient scenarios. Consequently, Health Net uses clinical validation by a team of experienced nursing and coding experts to further identify claims for potential billing errors. Clinical validation allows for consideration of exceptions to correct coding principles and may identify where additional reimbursement is warranted. Exceptions to general correct coding principles may be required to ensure adherence to health plan policies and to facilitate accurate claims reimbursement.

Health Net may request medical records or other documentation to verify that all procedures and/or services billed are properly supported in accordance with correct coding guidelines.

THIS UPDATE APPLIES TO:

  • Physicians
  • Medical Groups/IPAs
  • Hospitals
  • Ancillary Providers

STATE:

  • Oregon
  • Washington

LINES OF BUSINESS:

  • EPO
  • POS
  • PPO
  • CommunityCare
  • Medicare Advantage (HMO/PPO)

PROVIDER SERVICES

healthnet.com
EPO, POS, PPO, & CommunityCare – 1-888-802-7001
Medicare Advantage – 1-888-445-8913

PROVIDER COMMUNICATIONS

ORProviderCommunications@ TrilliumCHP.com
Fax 1-800-937-6086