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New and Revised Clinical Payment Policies and Code Editing Payment Policy Reminder for Marketplace

Date: 08/05/24

Superior HealthPlan presents new and revised clinical 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:

NEW AND REVISED CLINICAL PAYMENT POLICIES

EFFECTIVE DATE: NOVEMBER 1, 2024

POLICY

POLICY SUMMARY

 

APPLICABLE PRODUCTS

Pulmonary Function Testing

(CP.MP.242)

NEW clinical policy specification of the pulmonary function testing code and diagnosis combinations that are eligible for reimbursement, based on medical necessity guidelines.

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

 

Health Insurance Marketplace

(Ambetter from Superior HealthPlan)

EEG in the Evaluation of Headache

(CP.MP.155)

REVISED clinical policy that expands the range of diagnosis codes for EEG diagnostic testing that is not considered medically necessary.

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

 

Health Insurance Marketplace

(Ambetter from Superior HealthPlan)

ADHD Assessment and Treatment

(CP.MP.124)

  • Clinical policy number change from CP.MP.24 to CP.BH.124.
  • REVISED clinical policy to add the following codes and related indications as not medically necessary when billed with a sole diagnosis of ADHD: 70496, 70554, 70555, 78610, 84436, 84437, 84439, 84442, 84443, 84445, 84478, 84479, 84481, 92568, 92569, 92570, 95954, 96020, 96902, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036.
  • REVISED clinical policy to incorporate various edits in the policy, completed during the most recent annual review of the policy and detailed in the Policy Revision Log 03/23.

 

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

 

Health Insurance Marketplace

(Ambetter from Superior HealthPlan)

 

APPLICABLE AMBULANCE PROCEDURE CODES THAT MUST BE BILLED WITH PLACE OF SERVICE 41 (LAND) OR 42 (AIR/WATER):

EFFECTIVE DATE: SEPTEMBER 1, 2024

Ambetter from Superior HealthPlan will apply the CMS national billing standard for place of service on ambulance claims received on and after September 01, 2024.

Only two Place of Service codes are valid for ambulance claims:

  • Place of Service 41 (Land)
  • Place of Service 42 (Air/Water)

HCPC Procedure Code

HCPC Procedure Code Description

A0425

BLS mileage (per mile)

A0425

ALS mileage (per mile)

A0426

Ambulance service, Advanced Life Support (ALS), non-emergency transport, Level 1

A0427

Ambulance service, ALS, emergency

A0428

Ambulance Service, Basic Life Support (BLS) non-emergency transport

A0429

Ambulance service, basic life support (BLS), emergency transport

A0430

Ambulance service, conventional air services, transport, one-way, fixed wing (FW)

A0431

Ambulance service, conventional sire services, transport, on way, rotary wing (RW)

A0432

Paramedic ALS intercept (PI), rural area transport furnished by a volunteer ambulance company

A0433

Ambulance service, advanced life support, level 2 (ALS2)

A0434

Ambulance service, specialty care transport (SCT)

A0435

Air Mileage; FW, (per statue mile)

A0436

Air mileage; RW, (per statue mile)


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