Tag: #reimbursement

Posted in #reimbursement, 1199 SEIU Benefits Fund, Education, NY Providers, Payer Updates

NYS Medicaid: Bariatric Surgery Medical Policy Update

Posted on by KR2Medical Billing

Do you accept NYS Medicaid or Managed Medicaid Plan members? Then this blog post is for you!

Non surgical treatment should be attempted: ex. diet and increased exercise.

Bariatric Surgery Adult Patient: 18 years old and over

  1. BMI index 35 kg/m or greater OR
  2. BMI index 30-34.9 kg/m and a serious weight-related health problem (ex. High blood pressure, type 2 diabetes or severe sleep apnea)
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Pediatric patients: 18 years and older – patients that are deemed physically, mentally, and emotionally mature by a team of various providers ex. Pediatric provider, bariatric surgeon, and or other specialty providers.

  1. BMI- more and equal to 35 kg/m or more than 120% of 95th percentile of age and sex, whichever is lower AND with a weight-related health problem: ex. diabetes type 2, obstructive apnea – index or Reapiratory Disturbance Index greater than 5, Blount disease, non alcoholic steatohepatitis, slipped capital femoral epiphanies, GERD, hypertension, insulin resistance; or depressed health-related quality of life
  2. BMI greater than 40 kg/m or greater than 140% of the 95th percentile of age and sex, whichever is lower

Coding:

Most common codes that related to Bariatric Surgery

43644: Laparoscopic Roux-en-Y gastric bypass.

43775: Laparoscopic sleeve gastrectomy.

43770: Laparoscopic placement of an adjustable gastric band


43645: Laparoscopic malabsorptive procedure (e.g., [[Mini-gastric bypass|Mini-gastric bypass]]).

43848: Revision of a gastric restrictive procedure (open). 

NYS Medicaid coding and fee resources:

1. Physician Fee schedule- https://view.officeapps.live.com/op/view.aspx?src=https%3A%2F%2Fwww.emedny.org%2FProviderManuals%2FPhysician%2FPDFS%2FPhysician_Manual_Fee_Schedule_Sect5.xls&wdOrigin=BROWSELINK

2. Provider Manual- https://www.emedny.org/ProviderManuals/Physician/PDFS/Physician%20Procedure%20Codes%20Sect5.pdf

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Posted in #Medicare, #Medicareadvantage, #reimbursement, EmblemHealth NY, NY Providers, Payer Updates, Pharmacy (Various Insurance Payers), Training

Emblem Health new Specialty Meds/Pharmacy Policy

Posted on by KR2Medical Billing

Effective 7/14/25 there is a new specialty pharmacy policy will apply to all of Emblem Health lines of busines: commercial, Medicare, medicaid.

Image via emblemhealth

This policy applies to all outpatient providers in the following place of service: outpatient hospital, physician office,home of the member and ambulatory infusion.

Takeaways:

1. According to this policy the providers need to contact the respective specialty pharmacy to request prior auth and are only allowed to bill for specialty medications administration NOT the medication itself.

2. The Specialty Pharmacy will be allowed to bill Emblem health under the member’s medical benefit and receive reimbursement.

Image via EmblemHealth

3. For any Medicaid EmblemHealth plan- the medicatin codes must be on Medicaid Fee Schedule. If the code is not listed it will not be reimbursed.

Exclusion: this policy does not apply to home infusion providers.

For a full list of specialty medications please visit Emblem Health for more information and a PDF version of the policy

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Posted in #unitedhealthcare, Payer Updates, Prior Authorization Insurance Carrier Updates, Training

UHC Colorado: Rocky Mountain Health Plan-BH prior auth updates

Posted on by KR2Medical Billing

If you are a provider that accepts the following Rocky Mountain Health Plan types, then this blog post is for you:

  1. D-SNP: dual eligible special needs plan
  2. Child Health Plus
  3. Medicare Advantage
  4. Individual and Family plans
  5. Medicaid: RAE/PRIME

The following update will take affect for any DOS 7/1/25 and thereafter:

1.HCPCs – H2033, T2022- Multisystemic Therapy (MST), Enhanced MST: Requires pre-service notification, authorization necessary for services provided more than 90 days

2.H0036, T2022-Functional Family Therapy (FFT), Enhanced FFT: Requires pre-service notification, authorization necessary for services provided more than 90 days

3. G0137, H0015, Rev code 906- Substance use disorder intensive outpatient programming (SUD IOP): Requires pre-service notification, authorization necessary for services greater than 15 sessions

4. HCPCs code S9480, Rev code 905-Behavioral health intensive outpatient programming (BH IOP): Requires pre-service notification, authorization necessary for services greater than 15 sessions

5. Rev. code 0911-Psychiatric Residential Treatment Facility (PRTF): Requires prior authorization

6.H0019-Psychiatric Residential Treatment Facility (PRTF): Requires prior authorization

8. CPT codes: 6132, 96133, 96136, 96137, 96138, 96139, 96146, 96130, 96131-Neuropsychological and psychological testing (and related codes): Requires prior authorization

7. H0017- All services associated with H0017, including Acute Treatment Unit (ATU): Requires prior authorization

9. CPT codes- 96116, 96121- Neurobehavioral status exam: Requires prior authorization

To access the full list of codes, please click here: https://www.uhcprovider.com/en/prior-auth-advance-notification/adv-notification-plan-reqs.html and find the BH section

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