Commercial

Diagnostic Radiology Services Included in Capitation
00.03.02ab

Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

In specific regions of Pennsylvania (PA), primary care physicians (PCPs) are required to select a participating outpatient radiology site to provide most outpatient diagnostic radiology services to members on the PCP's HMO capitation panel. The selected radiology site (i.e., facility, ancillary, or professional provider) is the designated source for outpatient diagnostic radiology services that are included in capitation.

The diagnostic radiology procedure codes listed in Attachment A are included in capitation as part of the Company's Capitated Outpatient Diagnostic Radiology Program (CODRP) for HMO and HMO-POS product members who utilize their referred benefit and meet all of the following requirements:
  • Are age 12 and older
  • Are enrolled in a Commercial HMO or HMO-POS product
  • Choose a PCP in the following Philadelphia five-county area: Bucks, Chester, Delaware, Montgomery or Philadelphia
When the member does not meet the above requirements (e.g., members age 11 and under) covered outpatient diagnostic radiology services are eligible for reimbursement consideration on a fee-for-service basis.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be made available to the Company upon request.

Guidelines

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, outpatient diagnostic radiology services are covered under the medical benefits of the Company's products.

BILLING GUIDELINES
  • There may be circumstances when a procedure that is included in capitation may be provided by and eligible for reimbursement to a provider other than the designated radiology provider. Providers should refer to the Company's Provider Manual and provider communications for the requirements of and exceptions to the Capitated Outpatient Diagnostic Radiology Program (CODRP).

Description

Diagnostic radiology is the use of imaging modalities (e.g., x-ray, ultrasound) to obtain a diagnosis of a medical condition.

Capitation is the reimbursement that a participating facility, ancillary provider (e.g., freestanding outpatient radiology site), or professional provider receives in advance of services for a Health Maintenance Organization (HMO) member or for an Health Maintenance Organization Point-of-Service (HMO-POS) member who utilizes his/her referred benefit.

References

Company Benefit Contracts.

Company Provider Manuals.

Coding

CPT Procedure Code Number(s)
Refer to Attachment A for the list of codes for services included in capitation for Pennsylvania (PA) members.

ICD - 10 Procedure Code Number(s)
N/A

ICD - 10 Diagnosis Code Number(s)
N/A

HCPCS Level II Code Number(s)
Refer to Attachment A for the list of codes for services included in capitation for Pennsylvania (PA) members.

Revenue Code Number(s)
N/A



Coding and Billing Requirements


Policy History

1/1/2021
1/15/2021
00.03.02
Claim Payment Policy Bulletin
Commercial
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No