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Reminder: new ambulatory surgical grouper policy for commercial plans went into effect April 1, 2018

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Reminder: new ambulatory surgical grouper policy for commercial plans went into effect April 1, 2018

04/01/2018

Ambulatory surgical groupers will be paid as surgical when billed with revenue codes 360 or 490. If surgical services are billed with revenue codes other than 360 or 490, and the claim also includes charges for anesthesia and recovery, then the claim will be mapped as surgical and priced according to surgical contracted rates, unless otherwise negotiated.

The 2018 ConnectiCare Surgical Groupers list is not a guarantee of payment for a member’s treatment. Our claims edits and payment policies, including your group agreement terms and conditions with ConnectiCare, may affect our payment liability and a member’s cost-sharing obligations.

Mapping and assignment updates are effective for all providers as of April 1, 2018, except for new 2018 codes, which are effective Jan. 1, 2018.

For contracts that renewed between Feb. 1 and April 1, 2018, the new policy will go into effect after the next renewal of the contracts. Before then, surgical codes assigned group 0 for 2018 will map to contracted group 1 rates until contract is re-negotiated to include a 0-9 rate structure.

Please note, this updated 2018 ConnectiCare Surgical Groupers list includes code 27096 (inject sacroiliac joint) under grouper 1. An earlier list released in January incorrectly noted that the code was being deleted.

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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.