SHPBN-2019-038 Updated Ambetter Payment Policies
Date: 11/25/19
Effective January 15, 2020
Sunflower Health Plan is implementing payment and clinical policies that will guide how claims for certain services are adjudicated and paid. We will be instituting these policies to provide clinically based rule content to evaluate claims against payment and clinical policies to ensure accurate reimbursement. This is in addition to all other reimbursement processes that Sunflower Health Plan currently employs. The policies that dictate the coding and billing rules applied are based on industry standards and guidelines as published and defined in the Current Procedural Terminology (CPT), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society edits.
The effective date for these policies listed below is January 15, 2020. These policies apply to all Ambetter from Sunflower Health Plan Marketplace products, unless otherwise noted.
The policies can be found on the Ambetter from Sunflower Health Plan Clinical and Payment Policies web page.
| Number | Policy Name | Policy Description | Line of Business (LOB) |
|---|---|---|---|
| CP.MP.149 | PROM Testing | Premature rupture of membranes is a complication in pregnancy that can lead to preterm delivery. The purpose of this policy is to define medical necessity criteria for testing for rupture of fetal membranes using AmniSure®, Actim® PROM and the ROM Plus Fetal Membranes Rupture Test for the diagnostic evaluation for premature rupture of membranes. | Marketplace |
| CC.PP.054 | Physician Consult | To ensure provider’s bill the correct level of evaluation and management (E&M) CPT® codes when billing for physician’s consultation services. Furthermore, to encourage providers to bill consultation services based on 1) where the visit occurred and, 2) the complexity of the visit performed | Marketplace |
| CC.PP.052 | Problem Oriented -Surgical | Modifier -25 represents a significant and separately identifiable E&M service by the same physician or other qualified health care professional on the same day of the procedure or other service. | Marketplace |
| CC.PP.057 | Problem Oriented - Preventative | Under modifier -25 correct coding principles, a patient may be seen by the physician for both a preventative evaluation and management (E&M) service and a problem-oriented E&M service during the same patient encounter. Duplicate payments occur when a provider is reimbursed for resources not directly consumed during the provision of a service. | Marketplace |
| CC.PP.055 | Physician's Office Lab Testing (POLT) | The purpose of this policy is to define payment criteria for in-office laboratory procedures to be used in making payment decisions and administering benefits. Furthermore, to encourage the specialization of independent labs to ensure higher quality laboratory tests are performed in the appropriate setting. | Marketplace |
| CC.PP.053 | Leveling of ER Services | The purpose of this policy is to define payment criteria for emergency room services to be used in making payment decisions and administering benefits. | Marketplace |