May 2019 In The Know



The Claims Corner section of our provider website is a rich resource of information that helps your practice navigate EmblemHealth claims and billing processes.

Presumptive and Definitive Drug Testing
According to the National Correct Coding Initiative Policy Manual and CMS policy, presumptive drug testing may be reported with CPT codes 80305-80307. These codes differ based on the level of complexity of the testing methodology. Only one code from this code range may be reported per date of service.

Pilonidal Cyst Sinus Procedures
According to the AMA CPT Manual, Integumentary section, codes 10080-10081 (Incision and drainage of pilonidal cyst) or 11770-11772 (Excision of pilonidal cyst or sinus) must include an ICD-10 diagnosis code of Pilonidal Cyst or Pilonidal Sinus.
Frequency of Fundus Photography
According to CMS, the recommended frequency for Fundus Photography is no more than two times per 365 days except in unusual circumstances.
Duplicate Claims Policy: Non-Physician Practitioner
When EmblemHealth receives a claim from a Non-Physician Practitioner for the same services provided on the same date of service by another practitioner with the same tax ID and there is a match on the first three characters of the primary diagnosis code, it will be considered a duplicate regardless of provider ID and specialty.

Use of Modifier “QW” for tests granted waived status under Clinical Laboratory Improvement Amendment
CLIA waived tests are determined by the Food and Drug Administration (FDA) or Centers for Disease Control and Prevention (CDC) to be simple enough that there is little risk of error.According to CMS policy, modifier QW (CLIA waived test) can only be appended to procedures designated as CLIA waived tests on the clinical laboratory fee schedule. Refer to the CMS website for additional information.

Change in Medicaid Coverage for Child Annual Wellness Visits
Medicaid members less than 21 years old are now covered for an annual wellness visit once every calendar year. Previously, child wellness visits were only covered once every 12 months. More


Payment Policy Updates -  Durable Medical Equipment, Prosthetics, Orthotics, and Supplies
EmblemHealth has recently implemented changes to implement enhancements to our DME payment policies. Find a summary of these changes here.
Inpatient transfers between acute care hospitals/facilities
When a hospital or acute care facility does not have the services to ensure safe and/or quality care, it is the responsibility of the referring facility to contact the managing entity for all patient transfer requests by calling or faxing the applicable organization. The accepting hospital/acute care facility is responsible for confirming the transfer is authorized and to obtain the case number from the transferring facility. To avoid claim denials, the accepting facility must include the case number on all associated claim submissions. More
Utilization Review

New Utilization Management Pre-authorization List for Elective Services Starting July 1, 2019
A supplemental pre-authorization list for HIP members based on the member’s type of plan (Commercial and Medicaid) and the selected site of service is being introduced on July 1, 2019. More

Provider Update
eNews Policy Update