Posted in NY Providers, Payer Updates, Payers and CPT reinbursement, Training, Updates

MVP Health Plans: reimbursement of sick E&M codes billed w/preventative codes -05/01/23

According to the latest announcement MVP Health Plan will change the reimbursement of sick E/M codes when they are billed on the same day as a preventative codes.


This policy applies to Primary Care Physicians.


According to the new reimbursement policy the sick E&M codes will be reimbursed at 50% of allowable amount if the codes are billed on the same date of service as the preventative codes.


The reimbursement will be applied with or without the modifier 25 present.


Policy applies to the following codes:

Preventive medicine services are represented in evaluation and management (E/M) codes 99381ā€“99429. These E/M codes may be reported by any qualified physician or other qualified healthcare professional.


Preventative cpt codes 99381ā€“99397 for comprehensive preventive evaluations are age-specific, beginning with infancy and ranging through patients age 65 and over for both new and established office patients.

E&M codes may include: 99202-99205, 99212-99215

For more information please refer to MVP Evaluation and Management (E&M) policy.


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Posted in #unitedhealthcare, Payers and CPT reinbursement, Training, Updates

Michigan Medicaid: reimburses for Doula Services-01/01/23

The new coverage policy applies to Medicaid, Healthy Michigan Plan, MI Health Link, MIChild, Maternity
Outpatient Medical Services Programs.

Effective 01/01/23 – Michigan Medicaid members that belong to the above mentioned programs will be able to receive services from a certified doula during the the prenatal, labor and delivery, and postpartum
periods.


Doula- non clinical professional that provides physical, emotional, and educational support services to pregnant individuals.


In order for the Doula Services to be covered they need to be recommended by a licensed healthcare
provider.


Some of the Doula Services may include: (partial list) complete list is available click here.

Prenatal services, which include:
o Promoting health literacy and knowledge;
o Assisting with the development of a birth plan;
o Supporting personal and cultural preferences around childbirth;

Labor and delivery services, which include:
o Providing continual physical comfort measures, information, and emotional support;
o Advocating for beneficiary needs; and

Postpartum services, which include:
o Educating regarding newborn care, nutrition, and safety;
o Supporting breastfeeding;
o Providing emotional support and encouraging self-care measures;


Doula services are expected to be covered for face-to-face visits with the patient. Although the prenatal and Postpartum services may be done vial telemedicine, please MDHHS telemedicine policy.


Frequency: up to 6 visits are allowed plus 1 extra visit during the delivery. The duration of each visit needs to be at least 20 minutes. If the patient requires over the max allowed number of visits, then the provider may request more via PA process.


Documentation requirements: doulas need to document the start and end time of the visit for each patient. The documentation should include a description of the professional services rendered and information regarding the source of the licensed healthcare provider recommendation for services.


Reimbursement: in order to receive reimbursement doulas need to be a registered Michigan Medicaid Provider. Reimbursement amounts as follows:

Prenatal visit: S9445 Modifier- HD ICD-10 codes- Prenatal: Z33.1Postpartum: Z39.2 6 total visits Fee-$75 per visit

Attendance at Labor and Delivery: CPT code- T1033 Modifier- HD ICD-10 Code- Z33.1 Max 1 visit Fee- $700

For complete information regarding coverage/reimbursement/provider enrollment, please visit Michigan Medicaid Site click here.


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Posted in #unitedhealthcare, NY Providers, Payer Updates, Training

UHC NY Community Plan Referral requirement change-effective immediately

As per UniteHealthCare- NY community Plan -members will no longer require referrals to see specialists (most specialties).


This change is made to help Primary Care Physicians with reducing administrative burden and make it easier for the members to see some specialists.

The specialists that do or do not require a referral still need to be In Network with UHC NY Community Plan.


Below are the specialties that still require the referral. The members will need to contact their PCP office in order to obtain a referral and ensure that the Specialist will get reimbursed for the services provided.

  • Allergy and immunology
  • Dermatology
  • Endocrinology
  • Gastroenterology
  • General surgery
  • Neurological surgery
  • Orthopedic surgery
  • Otolaryngology
  • Physical medicine and rehabilitation/physiatry
  • Plastic surgery
  • Podiatry
  • Pulmonary medicine
  • Sports medicine
  • Urology
  • Vascular surgery

I am a provider, where should I go in order to request a referral?

Providers can request a referral on the UHC provider portal (UHCprovider.com ) Providers need to sign into the portal.


I am a provider and still have questions regarding the referral process, where should I go to find more infomation?

Provider can visit interactive guide in order to get more information regarding referral process.


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