Same Policy, New Look
The CPT and HCPCS Billing Guidelines (Commercial and Medicaid) reimbursement policy has a new look, but the rules remain the same. Whenever possible, please convert all HCPCS codes to the applicable CPT code prior to submitting claims to EmblemHealth and ConnectiCare.
Revised Policies
The following reimbursement policies have been updated. See the Revision History sections for updates and effective dates:
- ConnectiCare’s Laboratory/Venipuncture (Commercial and Medicare)
- Coding Edits Policies: EmblemHealth | ConnectiCare
- EmblemHealth’s Outpatient Diagnostic Imaging Self-Referral Payment Policy
- Anesthesia Reimbursement Policy
- Commercial Preventive Lists (EmblemHealth | ConnectiCare)
Reminders
Starting Jan. 1, 2023, we are introducing the following updates to our reimbursement policies:
- A new Foot Care Services and Nail Debridement Reimbursement Policy (Commercial, Medicare, and Medicaid), for both EmblemHealth and ConnectiCare.
- The EmblemHealth and ConnectiCare Modifier Reference Policy will align with CMS’ 10% payment reduction for claims submitted with modifiers FX (use of traditional x-ray film rather than digital radiography) and FY (x-rays taken using computed radiography technology/cassette-based imaging).
- ConnectiCare’s Commercial Preventive Services List will be updated with State of Connecticut’s new breast/ovarian cancer mandate criteria.
- The Coding Edits reimbursement policies will include new edits applicable to modifier JW (drug amount discarded/not administered to any patient) (EmblemHealth | ConnectiCare).
- A new From/To Date Span Policy, Facility and Professional (Commercial, Medicare, and Medicaid) Reimbursement Policy is being implemented to ensure we are only paying claims with properly documented dates of service. If the date of service submitted for a procedure is out of the “From” and “To” date calendar range or not in the correct format, claims will be denied.
