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Univera will no longer reimburse preventive codes with problem-oriented codes

December 30, 2019

Practicefirst was recently notified by Univera of a new administrative policy effective March 15, 2020, to define the coverage and billing guidelines for preventive services billed on the same day as a problem-oriented visit by the same individual provider for the same member. This policy is in line with the Centers for Medicare & Medicaid Services and Current Procedural Terminology (CPT) guidelines.This policy will apply to all participating practitioners and all lines of business.

 

  • Univera will reimburse a preventive E&M service when it is rendered by the same individual provider on the same day as a separately identifiable problem-oriented E&M service. Reimbursement for the higher valued service will be made at 100% of the contracted allowable rate and the lower valued service will be made at 50% of contracted allowable rate.

 

  • The Health Plan will not reimburse new patient problem-oriented visit codes 99201-99205 when billed with new patient preventive visit codes 99381-99387 during the same encounter. 

 

  • This policy will be reviewed pre-payment. Pre-payment review means claims are reviewed prior to payment. A pre-payment review results in an initial determination. Post-payment review means the claims are reviewed after adjudication. 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’s discretion. Members are held harmless for all denials resulting from this administrative policy.

 

You can access the individual policies at: www.UniveraHealthcare.com/Adminpol. As a reminder, you must login with your username and password to access the administrative policies.

 

For Billing questions, please contact Tammy Bartlett at 716-389-3223 or tammyb@pracfirst.com.

 

 

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