Notification



Notification Issue Date:



Claim Payment Policy


Title:New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances

Policy #:00.01.55o


Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, 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 decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

This policy applies to providers billing on a CMS-1500 claim form or the electronic equivalent, 837p, for members enrolled in all New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Company products.

The New Jersey HMO and HMO-POS Network Rules and limited circumstances are as follows:
  • Radiology services under the HMO and HMO-POS benefit program (Radiology Network Rules and Limited Circumstances, Attachment A1) are considered eligible for payment in an outpatient and office setting when performed by a radiologist or pediatric radiologist at a contracted radiology site.
  • The limited circumstances of radiology services that a participating specialist, (this includes Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs) practicing within these specialty groups), other than a radiologist or pediatric radiologist, may provide, and for which the provider may be eligible for reimbursement, are listed in Attachment A2. Refer to attachment A2 for the specific provider specialties and eligible codes.
  • All other provider specialties are considered ineligible to provide radiology services, unless otherwise identified by specialty and code in attachment A2.

Generally, individuals enrolled in HMO or HMO-POS products using their referred benefit are required to obtain a referral and/or precertification prior to services being rendered by a participating specialist provider.

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.
Guidelines

Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

BENEFIT APPLICATION

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

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the group benefit contract is issued determine the mandated coverage.

Description

The New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances policy identifies radiology services that are eligible for reimbursement consideration when reported in the office or outpatient hospital places-of-service by participating New Jersey professional providers.

In general, radiology services are eligible for reimbursement consideration when reported by a participating radiologist or pediatric radiologist. There are limited circumstances when it may be medically necessary for a participating specialist, other than a radiologist or pediatric radiologist, to perform a radiology service in the office or outpatient hospital places-of-service. These limited circumstances are identified by provider specialty, place-of-service, and procedure code.

Radiology services encompass the scientific discipline of medical imaging, which utilizes ionization radiation, radionuclides, magnetic resonance, and ultrasound.
References


Company Benefit Contracts.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

See attachments A1 and A2


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD-10 Diagnosis Code Number(s)

N/A


HCPCS Level II Code Number(s)

See Attachments A1 and A2


Revenue Code Number(s)

N/A


Coding and Billing Requirements


Cross References

Attachment A1: New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
Description: NJ HMO & HMO-POS RADIOLOGY NETWORK RULES

Attachment A2: New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
Description: NJ HMO & HMO-POS RADIOLOGY LIMITED CIRCUMSTANCES



Policy History

00.01.55o:
01/01/2020This version of the policy will become effective 01/01/2020.

The following codes have been deleted from this policy: 0482T, 74241, 74245, 74247, 74249, 74260, 78205, 78206, 78320, 78607, 78647, 78710, 78805, 78806, 78807, G0365

The following codes have been added to this policy: 78429, 78430, 78431, 78432, 78433, 78434, 74221, 74248, 93985, 93986, 77063

The following codes have been revised this policy: 74210, 74220, 74230, 74240, 74246, 74250, 74251, 74270, 74280, 78459, 78491, 78492, 78800, 78801, 78802, 78803, 78804

00.01.55n:
01/01/2019This version of the policy will become effective 01/01/2019.

The following CPT & HCPCS codes have been deleted from this policy: 0346T, 77058, 77059, 78270, 78271, 78272

The following CPT codes have been added to this policy: 0541T, 0542T, 76391, 76978, 76979, 76981, 76982, 76983, 77046, 77047, 77048, 77049

The CPT narratives have been revised for the following code in this policy: 77387

00.01.55m:
01/01/2018This policy has been identified for the CPT code update, effective 01/01/2018.

The following CPT codes have been added to this policy:
0482T, 71045, 71046, 71047, 71048, 74018, 74019, 74021

The following CPT code has been deleted from this policy:
71010, 71015, 71020, 71021, 71022, 71023, 71030, 71034, 71035, 74000, 74010, 74020, 77422, 78190, G0202, G0204, G0206

The following CPT narratives have been revised in this policy:
76000, 76881, 76882

REVISIONS FROM 00.01.55l:
12/01/2017Revised policy number #00.01.55l was issued. Effective 12/01/2017, Physician Assistants (PAs) are eligible to perform services in in a specialty group.


Effective 10/05/2017 this policy has been updated to the new policy template format.


Version Effective Date: 01/01/2020
Version Issued Date: 05/19/2020
Version Reissued Date: N/A



2017 AmeriHealth.