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Payment Policy Posting and Updates

Date: 12/20/24

Superior HealthPlan, Ambetter from Superior HealthPlan and Wellcare By Allwell present new and existing payment policies as detailed below. As a result, the following policies have been posted on Superior’s Clinical, Payment and Pharmacy Policies webpage for awareness, prior to implementation:

POLICY

EFFECTIVE DATE

APPLICABLE PRODUCTS

NEW POLICY OVERVIEW OR UPDATED POLICY REVISIONS

TX.CC.PP.011

Code Editing Policy

12/15/24

Health Insurance Marketplace (Ambetter from Superior HealthPlan)

Medicare (Wellcare By Allwell [HMO, HMO D-SNP])

Coding Reminder:  Billing for Electrodes

Consistent with the health plan code editing pre-payment policy, claims will be denied when A4556 (Electrodes, [e.g., apnea monitor], per pair) is billed, and diagnosis code(s) on the claim indicate it has been billed as a transcutaneous electrical nerve stimulation (TENS) electrode. TENS supply allowance (A4595) is an all-inclusive code and includes items such as electrodes (A4556).

CC.PP.501

30 Day Readmission

02/01/25

Medicaid (STAR, STAR Health, STAR Kids, STAR+PLUS), CHIP

Post Pay reviews will be performed for inpatient readmissions determined to have been inappropriate or preventable.  Readmission claims will be determined to be overpayments when the readmission:
  • Was medically unnecessary;
  • Resulted from a prior premature discharge from the same hospital or a related hospital;
  • Resulted from a failure to have proper and adequate discharge planning;
  • Resulted from a failure to have proper coordination between the inpatient and outpatient health care teams; and/or
  • Was the result of circumvention of the contracted rate by the hospital or a related hospital.

 

To review all policies, please visit Superior’s Clinical, Payment and Pharmacy Polices webpage. For questions or additional information, please contact Provider Services at: