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Commercial - Billing & Claims Payment Policy

Overview of Policy

ConnectiCare has policies in place that reflect billing or claims payment processes unique to our health plans. Current billing and claims payment policies apply to all our products, unless otherwise noted. ConnectiCare will inform you of new policies or changes in policies through future editions of the Manual and by specific notice for changes that we determine would be material for a significant provider population. If a billing or claims payment policy for a particular service is not addressed in this outline, follow procedures that are considered standard throughout the health care industry. Most of ConnectiCare’s billing and claim payment policies are standard in the health insurance industry, and you should follow industry standard procedures for issues that are not specifically addressed in the Manual.

We also evaluate medical billing information to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures. ConnectiCare reserves the right to audit physician documentation in order to verify coding and billing accuracy.

ConnectiCare's claims system will process claims based on CMS (Centers for Medicare and Medicaid Services) and NCCI (National Correct Coding Initiative) edits. ConnectiCare follows coding edits that are based on industry sources, including, but not limited to, CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there appears to be conflicts between sources, we will apply the edits we determine are appropriate. ConnectiCare uses ClaimCheck^® and Integrated Claims Management Services^sm claims editing software products when making decisions about appropriate claim editing practices. Upon request, we will provide an explanation of how ConnectiCare handles specific coding issues.

OVERVIEW OF POLICY

Title	Effective Date	Policy Statement	Billing Instructions	Reimbursement Information
All Providers
After Hours Care	January 2006	ConnectiCare will reimburse for the proper use of CPT 99050 for services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed. This code will not be reimbursed by CMS, however, ConnectiCare recognizes the need to reimburse for in-office services when the office is normally closed. ConnectiCare will not reimburse for CPT 99051 or 99053.	When services are provided after regularly scheduled office hours, the provider may bill with 99050 in addition to the appropriate E&M code. When services are provided during regularly scheduled office hours in the evening, on weekends and holidays, the provider may bill with the appropriate E&M code only. 99050 should not be used. 99051 or 99053 will not be reimbursed.	Reimbursement for the proper use of 99050 and the appropriate E&M codes will be in accordance with applicable fee schedules.
Bundled Status Codes	August 1998, revised December 2004	ConnectiCare follows all CMS Relative Value Unit (RVU) file recommendations for the following: • Status Code B, for which reimbursement is considered bundled with payment for other services. • Status Codes P and X, when covered, will be reimbursed only to ancillary providers, such as DME, home care, or pharmacy providers. Some exceptions may apply. Refer to the RVU file for more details		Reimbursement for bundled status codes is considered included in the related therapeutic or diagnostic service.
CPT, HCPCS and ICD Coding	June 1997, revised January 2005	ConnectiCare requires the use of current CPT, HCPCS and ICD-9 coding. Deleted procedure codes will no longer be accepted after the deleted date.
Date Spanning	April 2001	When multiple, like services are billed for more than one date of service, ConnectiCare requires that the services be billed on separate line, based on the date of service. Claims not submitted in this manner will be denied and returned for revision. Exclusion: IV therapy services.	Bill each date of service on a separate line. The number of units on each line should equal one (1). For example, if CPT 99232 (subsequent hospital care per day) is billed for dates of service DOS) 2/2 - 2/4 then the claim should be submitted as follows: Line 1: 99232 - DOS 2/2 Line 2: 99232 - DOS 2/3 Line 3: 99232 - DOS 2/4
Immunization (including flu vaccines)	July 2000	Immunizations (vaccine & administration) are covered when provided in accordance with the guidelines set forth by the American Academy of Pediatrics and the Advisory Committee on Immunization Practices. Immunization services must be submitted correctly with the appropriate CPT code to ensure accurate reimbursement. Note: The administration of covered vaccines is at the discretion of providers, including flu vaccine. There are no restrictions.	Refer to the most current CPT coding manual for applicable billing codes. General billing guidelines include: • The administration of the flu and peumococcal vaccines may be billed separately, unless other reimbursement arrangements have been contracted. • A copayment should not be taken for only the provision of an immunization, unless the immunization is provided as part of an office visit for another separate service(s). Note: For State supplied vaccines charge $0.00 per vaccine. ConnectiCare will reimburse the administration charge only.	Reimbursement will be made according to applicable fee schedules.
Mid-level Practitioners	November 1999, revised January 2005	ConnectiCare recognizes licensed, mid-level practitioners as a separate provider type when working under the supervision of a participating physician. Mid-level practitioners are reimbursed at 85% of the allowable amount, regardless of the location where services are provided. This is consistent with CMS policy. Mid-levels are reimbursed at 100% for only certain procedures noted to the right. Note: Mid-level practitioners who join an IPA/PHO that already participates with ConnectiCare must obtain their own separate contract with ConnectiCare.	Use assigned ConnectiCare mid-level provider ID#. It is not necessary to use modifier -81 or AS unless assisting with surgery in an inpatient location. Also see Assistant at Surgery Billing & Reimbursement found later in this section.	CPT codes are reimbursed at 85% of fee schedule except the following codes, which are reimbursed at 100% of fee schedule: 90281-90399; 90471-90474; 90476-90749; 90780-90799; 91000-91299; 92511-92533; 92551; 92567; 93000-93350; 94010-95078; 96910; 96912; J codes; HCPCS; laboratory & radiology, according to in-office rules outlined in section 4a.
Moderate Sedation	January 2006	ConnectiCare follows: • AMA CPT coding guidelines • CMS NCCI Manual (edits and policies), • CMS Medicare Claims Processing Manual (Publication 100-04, Chapter 12, Section 50) for moderate (conscious) sedation.	• Moderate sedation codes are CPT 99143-99145 and 99148-99150. • CPT codes 99148-99150 require documentation supporting the need for the second physician to administer moderate sedation. These codes are not to be reported when performed in a non - facility setting (e.g., physician office). • Moderate sedation does not include 00100-01999.	• Moderate sedation codes will be reimbursed in accordance with AMA CPT guidelines and applicable CMS references.
Multiple Procedure Reduction	January 2006	ConnectiCare follows CMS guidelines for codes that are subject to multiple procedure reduction.	The reimbursement schedule shown in the next column applies to the CPT procedure codes subject to multiple procedure reduction as defined by CMS.	Surgical Procedures: Primary procedure - 100% of allowable (highest allowable fee) • 2nd surgical procedure — 50% of allowable fee • 3rd & subsequent surgical procedures —25% of allowable fee Radiological Procedures: reimbursed according to CMS reduction applied to contracted fee schedules. Note: ConnectiCare does not follow CMS's percent reduction schedule as our fees are higher than CMS. For additional information go to www.cms.hhs.gov.
Multiple Surgical Procedures	May 2002	Reimbursement for multiple surgical procedures (those performed by the same physician on the same day or during the same operative session, and may be on different parts or areas of the body) is reduced after the primary surgical procedure (that which has the highest allowable fee).	The reimbursement schedule shown in the next column applies to CPT procedure codes in the 10021- 69990 range. Certain CPT codes are not subject to payment reduction. These codes are based on the cur- rent year Relative Value Units (RVU) file obtained from CMS.	Primary surgical procedure - 100% of allowable (highest allowable fee) • 2nd surgical procedure — 50% of allowable fee • 3rd & subsequent surgical procedures —25% of allowable fee
Non-licensed Personnel	January 1999	ConnectiCare will not reimburse for services provided by non-licensed health care personnel (e.g., home health aids, physical therapy assistants, nannies, certified surgical or nursing assistants).
Nutritional Counseling	January 2000	ConnectiCare covers nutritional counseling, rendered by participating providers in the office or outpatient facility. Coverage is limited to two visits per member, per calendar year, and must be for illnesses requiring therapeutic dietary monitoring (e.g., diabetes, heart disease, hypertension, obesity). In some cases, an additional visit may be authorized.	Bill with CPT codes 97802, 97803, 97804, 99078 or 0942.	Reimbursement will be made according to applicable fee schedules.
Removal of Skin Lesions	February 2002	The cosmetic removal of benign lesions (including hypertrophic/keloid scars), or the removal of skin tags is not covered and may not be pre-authorized. All other procedures for removal of skin lesions are covered benefits.	Refer to the most current CPT and ICD-9 manuals for applicable billing codes.
Sleep Studies	December 2011	ConnectiCare covers one complete sleep study per lifetime per member when provided by participating providers at facilities that are AASM (American Academy of Sleep Medicine) accredited.	Acceptable CPT codes: 95805, 95807-95811 Acceptable diagnosis codes: 347.0-347.01; 333.94; 333.99; 307.4-307.49; 327.23; 780.5-780.59
Services associated with prior authorized services	January 1, 2009	Services associated with procedures that require prior authorization will be denied when no authorization has been obtain or has been denied. Upon appeal, if the procedure requiring authorization is authorized retroactively, the related services may be reimbursed.
Unlisted Codes	January 2001	ConnectiCare will provide reimbursement for covered, unlisted CPT and HCPCS codes. Note: Some exceptions may apply.	The codes listed under Reimbursement Information do not require documentation; with the following exceptions: 42299, 59899, 84999, 86849, 97799, 01999, 59898. These codes do require documentation before reimbursement will be provided. According to the American Medical Association, when performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided.	Unlisted CPT codes: • CPT 10040-69990 - 65% up to a maximum of $500/member per date of service • CPT 80049-89240 - 65% up to a maximum of $100/member per date of service • All other CPT codes - 65% up to a maximum of $300/member per date of service Unlisted HCPCS: &bull Codes billed in office - 65% of amount billed • All other HCPCS codes - per contracted rate
Venipuncture	December 2007	ConnectiCare follows CMS coding policy for billing of venipuncture CPT code 36415. This code should be used for all routine venipuncture for specimen collection. ConnectiCare will audit provider claims submitted with CPT 36410, and may request a refund if found to be billed inappropriately.	• Bill all routine venipuncture for specimen handling with CPT 36415. • Use CPT 36410 only when the venipuncture must be performed by a physician.
Allergists
Allergy Testing & Treatment (Excludes ConnectiCare of NY, Inc. plans)	June 1992; revised January 2004	Allergy Testing services are limited under member benefit maximums (1 - $315/2 years for allergenic extracts; 2 - $315/2 years for drug, biological venom testing). The member may be billed after the member maximum is met.	Allowable CPT codes: Allergy Testing: 95004, 95010, 95015, 95024, 95027, 95028, 95044, 95052, 95056, 95075, 95078, rev. code 0924 Allergy Treatment: 95115, 95117, 95120, 95125, 95130-95134, 95144 - 95149, 95165; 95170 Administration of Allergen Immunotherapy: 95165, 95144 – 95149, 95170, 95180 (will deny when billed with 95120, 95125, 95130 - 95134) Office Visit (only bill if other significant, separately identifiable services are provided at same time; codes appear with modifier “25”)
Anesthesiologists
Anesthesiology Billing	February 1998	Anesthesia services indicated by CPT codes 00100-01995, 01998 and 01999 that are performed by anesthesiology providers, must be billed in minutes (except for electronically submitted claim, see next column). CPT code 01996 should be billed as one unit; no minutes should be billed for these codes. Anesthesia modifiers P1 - P6 may be billed in addition to CPT codes 00100 - 01999.	Paper Claims: Anesthesia CPT codes should be billed in minutes. ConnectiCare will divide the number of minutes billed by 15 (the anesthesia unit equivalent) and add that number to the assigned Basic Unit Value to determine total anesthesia units. Allowable, non-anesthesia CPT codes should be billed as one (1) service unit. Electronic Claims: Bill in units, not minutes (units = base unit value + [minutes/15]). Do not include units associated with modifiers P1 - P6 in the total units being billed. At the time of processing ConnectiCare will adjust total units to account for the units associated with modifiers P1 - P6. ConnectiCare also requires that the “from” and “to” times be provided. Note: Additional information regarding modifiers appears later in this section.	Anesthesia CPT codes will be reimbursed based on the applicable fee schedule for anesthesia units. Allowable non- anesthesia CPT codes will be reimbursed based on the applicable physicians’ fee schedule, with a maximum of one (1) unit. When more than one anesthesia service is billed for the same date of service, base units will be reimbursed only for the procedure with the highest base unit value. Lesser procedures will be reimbursed for time only.
Obstetrician/ gynecologists
Maternity Billing Procedures	May 1994	ConnectiCare requires the use of global delivery codes when the same physician or same physician group provides care throughout the pregnancy and delivery. These codes include one postpartum visit.	• Bill antepartum care as part of the global delivery codes 59400 and 59510. Either 59425 or 59426 may be used if the physician or group did not provide care throughout the pregnancy and delivery.. • Modifier 22 can be billed in conjunction with any delivery service for high-risk patients who require 16 or more antepartum visits, or in the case of a multiple gestation pregnancy.	E & M codes 99211 - 99285, antepartum codes 59425-59426, and urinalysis codes 81000 & 81002 are not reimbursed if billed with a routine pregnancy code, and with a date of service up to 180 days prior to a previously paid delivery code.
Osteopaths
Osteopathic Manipulative Treatment (OMT) for the Personal Care Plan	April 1995	Any DO may provide treatment for Osteopathic Manipulative Treatment (OMT) codes 98925-98929. A PCP referral is required if the DO performing OMT is not the patient's PCP.	The DO may charge for a consultation in addition to the fees for OMT, in accordance with CPT guidelines for separate Evaluation and Management services.
Radiologists
Bilateral Radiology Procedures	April 1995	When submitting claims for bilateral radiology procedures, submit the procedure code for both procedures on one service line and indicate the number of services as “2”. “RT” and “LT” are also acceptable modifiers with the CPT code when used in place of units in the office location only.
Surgeons
Assistants at Surgery Billing & Reimbursement	January 1999	ConnectiCare will reimburse assistant surgeon and assistant-at-surgery services when billed with surgical procedure codes and when recommended by ConnectiCare’s code editing software. Surgeons are responsible for notifying any non-participating assistant surgeon or assistant-at-surgery of billing requirements.	Physicians who perform assistant surgeon services should bill (under their own ID number) the surgical CPT code with modifier ‘- 80’ or ‘-82’, as applicable. Physician assistants or other licensed mid-level practitioners who perform assistant-at-surgery services should bill the surgical CPT code with modifier ‘81’ or ‘AS’. Also see Mid-level Practitioners.	Allowable services billed with modifier ‘-80’ or ‘-82’ will be reimbursed at 20% of the primary surgeon’s fee. Allowable services billed with modifier ‘-81’or ‘AS’ will be reimbursed at 10% of the primary surgeon’s fee.
Bilateral Surgical Procedures	May 2002	Surgeons should bill for all bilateral surgical procedures performed during the same operative session using the five-digit CPT code describing the procedure, followed by the bilateral Modifier ’-50’, a 2-digit code which indicates a service is bilateral.	1. When billing a bilateral procedure, bill the five- digit CPT code with a Modifier ‘-50’ on one (1) service line. 2. The number of services/units billed should be one (1). Note: The use of Modifier ‘-50’ is restricted to surgical CPT codes 10021-69990, when appropriate, per the National Physician Fe Schedule Relative Value File. The Modifier ‘-50’ is not allowed where the surgery code description already describes the procedure as “bilateral”.	Each bilateral procedure counts as two (2) services and is reimbursed following the schedule outlined in the Multiple Surgical Procedures policy outlined later in this section. • 1st bilateral procedure —150% of allowable fee (considered 1st & 2nd procedures, 1st reimbursed at 100% and 2nd reimbursed at 50%) • 2nd bilateral procedure —50% of allowable fee (considered 3rd & 4th procedures, reimbursed at 25% each) • 3rd and subsequent bilateral procedures —50% of allowable fee
Global Surgical Billing	August 1998	ConnectiCare recognizes CMS (Centers for Medicare and Medicaid Services) global surgical periods. Physicians should not require members to have a separate encounter solely for the purpose of being able to bill for an office visit separate from a diagnostic or therapeutic procedure.

If you have any questions, please call Provider Services at 860-674-5850 or 1-800-828-3407.

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Commercial Physician & Provider Manual

Headlines

Commercial - Billing & Claims Payment Policy

Overview of Policy