Tag: #reimbursement

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

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

Posted on by KR2Medical Billing

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 Training, Updates

UHC Oxford- updated Prior Auth changes 01/01/2023

Posted on by KR2Medical Billing

Starting 01/01/2023 Oxford will add and remove certain codes that require prior authorizations (commercial line of business).

According the Oxford this change helps align their processes with evidence-based clinical guidelines.

Some of the new codes that will be added are:

For a full list of new codes that will be added to the list of codes that require prior authorization, please click here.

In addition Oxford is also adding a new provider tool, the UnitedHealthcare Oxford plan Prior Authorization Requirements document, it will become available as of Dec. 1, 2022, on the Advance Notification and Clinical Submission Requirements page.

Providers are encouraged to use this tool where they will be able to find/research codes that require prior authorization as well as request an auth.

Would you like to learn more: please click here, for the Applicable Oxford Commercial policies.

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Posted in #Medicareadvantage, BCBS (Various States), Training, Updates

BCBS of MN: Reimbursement update (modifiers 52, CO, CQ)

Posted on by KR2Medical Billing

Please note which type of providers will be affected by each reimbursement policy for specific modifiers and the effective date it begins.

The following reimbursement updates take effect as of July 1, 2022:

  1. Modifier 52- for services performed on 07/01/2022 and thereafter, Blue Cross will be begin reimbursing procedure codes billed with a -52 modifier at the lesser of 50% of the physician fee schedule allowance or charge submitted for the following lines of business: • Commercial• Federal Employee Program (FEP)
  2. The Reimbursement Policy, General Coding – 003 Coding Edits will be updated to reflect this change.

PT/OT/ST services reimbursement with modifiers CO, CQ for DOS 07/01/2022 and thereafter:

  1. Commercial plans-

Blue Cross will be implementing a 15% reduction in the allowed amount for services
modified with CO or CQ modifier for professional providers.

The following reimbursement Policy took affect for DOS 01/01/2022 and thereafter

1. Medicare Advantage Plans-

Blue Cross implemented a 15% reduction in the allowed amount for services modified with CO or CQ modifier for professional and facility providers to comply with requirements of the Centers for Medicare & Medicaid Services (CMS).

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