Federal and state law, as well as state contract language, including definitions and specific contract provisions/exclusions, take precedence over these PA rules and must be considered first when determining coverage.
Currently Anthem Medi-Cal reimburses for services for a covered member prior to admission to an inpatient hospital (referred to as the payment window) unless provider, state, federal or CMS contracts and/or requirements indicate otherwise.
However, Emergency and observation services are included in the inpatient reimbursement and, therefore, are not separately reimbursable expenses when performed within 24 hours prior to and including the day of the member’s admission.
Effective 05/01/21- Anthem Medi-Cal the following changes will take effect:
For admitting hospitals: preadmission services are included in the inpatient reimbursement for the three days prior to and including the day of the member’s admission. Therefore, they are not separately reimbursable expenses.
Anthem will not consider the following services to be included in the payment window prior to an inpatient stay for preadmission services:
Ambulance services
Maintenance renal dialysis services
Services provided by:
Skilled nursing facilities
Home health agencies
Hospices
Unrelated non-diagnostic services
If you have more information please visit:https://mediproviders.anthem.com/ca. and review Preadmission Services for Inpatient Stays reimbursement policy
Update: Oxford/UHC/ NYSHIP (Empire Plan) and 1199 DO NOT PAY FOR THIS CODE.
As of 09/08/20-there is a new CPT code 99072 became available for PPE.
Definition 99072:
Additional supplies, materials, and preparation time required and provided by the physician or other qualified health care professional and/or clinical staff over and above those usually included in an office visit or other service(s), when performed during a nationally declared public health emergency due to respiratory transmitted infectious disease.
Coding Guidelines:
Code 99072 is to be reported only once per in-person patient encounter per provider identification number, regardless of the number of services rendered at that encounter.
Code 99072 is designed to capture the following practice expense factors:
Time over what is included in the primary service of clinical staff time to conduct a pre-visit phone call to screen the patient (symptom check), provide instructions on social distancing during the visit, check patients for symptoms upon arrival, apply and remove personal protective equipment, and additional cleaning of the examination/procedure/imaging rooms, equipment and supplies
Three surgical masks
Additional cleaning supplies (e.g., hand sanitizers, disinfectant wipes)
HOWEVER, as of 09/09/2020 as per NY STATE DOH there was a letter sent out to providers from various insurance payers: Anthem BCBS (Empire), MVP, EmblemHealth warned providers not to collect any copay, coinsurance for PPE.
IF the patient was charged for PPE, the provider has to refund they should issue a refund to members immediately and contact your Empire Network Services representative to report the following:
Member(s) impacted
Total refunded to member(s)
The refund process
Below are the links to the announcements that were went to the NY providers from above mentioned insurance payers/ NY DFS Letter :
KR2 Medical Billing 