Billing and Reimbursement Guidelines
Practicefirst was recently notified by Univera of the following administrative policy effective May 15, 2020, to define the billing and reimbursement guidelines for increased procedural services (i.e., modifier 22) billed on professional claims. This policy is in line with the Centers for Medicare & Medicaid Services and CPT guidelines.
The new policy will apply to all practitioners and the following lines of business: Commercial (HMO, PPO, POS, ASO/ASC and Indemnity), Medicare Advantage, NYS Government Programs, Medicaid Managed Care, Health and Recovery Plan, Child Health Plus and Special Programs (Healthy NY and Essential Plan).
Claims for services billed with a modifier 22 are reviewed and approved by a Health Plan medical director. The Health Plan will reimburse codes reported with, and approved for, modifier 22 at 118 percent of the applicable fee schedule.
Services billed with Modifier 22 that are not approved by a medical director or were not submitted with medical records to support the increased procedural service billed, will be reimbursed at the applicable standard fee schedule.
Reimbursement for increased procedural services requires documentation that details the specific increased work and complexity that necessitated use of modifier 22.
This policy will be reviewed pre-payment. A post-payment review may result in either no change to the initial determination or a revised determination.
These services are subject to audit and policy updates at Univera Healthcare’s discretion. Members are held harmless for all denials resulting from the Administrative Policy. The individual policies can be accessed on the Univera website: UniveraHealthcare.com/Adminpol.
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