The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member's medical needs and condition.
This policy applies to professional providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, and outpatient facility providers billing on a CMS-1450 (UB-04) claim form or the electronic equivalent, 837i, for members enrolled in all Company products.
Multiple procedure payment reduction (MPPR) guidelines apply when both a transvaginal and transabdominal (obstetric or non-obstetric) ultrasound is reported for the same individual, by the same professional or facility provider, or providers within the same group or same facility healthcare system, on the same date of service.
The hierarchy for MPPR guidelines is set forth below:
- The procedure code with the highest allowance is eligible for reimbursement consideration at 100 percent of the provider's applicable contracted rate.
- Each subsequent procedure code is eligible for reimbursement consideration at 50 percent of the provider's applicable contracted rate.
MPPR guidelines for transvaginal and transabdominal ultrasounds are not applied to services that are non-covered or not eligible for separate reimbursement consideration.
MPPR guidelines for transvaginal and transabdominal ultrasounds are not applied to procedure codes that are classified by the American Medical Association (AMA) as add-on codes or Modifier 51 exempt codes, and HCPCS codes classified by the Company as add-on codes.
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 professional provider's office, hospital, nursing home, home health agencies, therapies, 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 available to the Company upon request. Failure to produce the requested information may result in a denial for the service.
BILLING REQUIREMENTS
The Company requires two or more procedures or services performed for the same member, by the same performing provider, on the same date of service, to be reported on a single claim form.
