We are introducing a formalized reimbursement policy, Multiple Procedure Payment Reduction Cardiology/Ophthalmology, which applies to both EmblemHealth and ConnectiCare. There are no changes to the guidelines or criteria we have been using to process claims.
ConnectiCare’s payment policy, ASC Grouper 2023 Commercial, was updated Oct. 1, 2023, to include new codes. Ambulatory surgical groupers will be paid according to surgical contracted rates when billed with revenue codes 360 or 490. If surgical services are billed with revenue codes other than 360 or 490 – and the claims contain charges for anesthesia and/or recovery room – claims will be paid according to the surgical contracted rates unless otherwise negotiated.
The following Reimbursement Policies have been updated. See their revision histories for applicable changes.
- Coding Edits Policies: EmblemHealth | ConnectiCare.
- Preventive Services Lists (Commercial): EmblemHealth | ConnectiCare.
- Preventive Services Lists (Medicare): EmblemHealth | ConnectiCare.
- Revenue Codes Requiring Detailed Coding.
The following Laboratory Benefit Management (LBM) policies have also been updated. See their revision histories for applicable changes.
- Biomarkers for Myocardial Infarction and Chronic Heart Failure (LBM).
- Cardiovascular Disease Risk Assessment (LBM).
- Coronavirus Testing in the Outpatient Setting (LBM).
- Diagnosis of Vaginitis including Multi-target PCR Testing (LBM).
- Erectile Dysfunction (LBM).
- Folate Testing (LBM).
- Gamma-glutamyl Transferase (LBM).
- General Inflammation Testing (LBM).
- Genetic Testing for Adolescent Idiopathic Scoliosis (LBM).
- Identification of Microorganisms Using Nucleic Acid Probes (LBM).
- Oral Cancer Screening and Testing (LBM).
- Pancreatic Enzyme Testing for Acute Pancreatitis (LBM).
- Pathogen Panel Testing (LBM).
- Prenatal Screening (Nongenetic) (LBM).
- Prescription Medication and Illicit Drug Testing in the Outpatient Setting (LBM).
- Serum Tumor Markers for Malignancies (LBM).
- ST2 Assay for Chronic Heart Failure (LBM).
- Testing for Alpha-1 Antitrypsin Deficiency (LBM).
- Testing for Vector-Borne Infections (LBM).
- Urine Culture Testing for Bacteria (LBM).
- Zika Virus Risk Assessment (LBM).
