Medic aid denial reference

In the event there are no pediatric-specific criteria, the default criteria for pediatrics are the adult or general criteria.

9 - 1 Unspecified Services and Procedures

Unspecified services or procedures covered by Medicaid do not require prior authorization. These codes typically are five numbers ending ". . . 99". Do not use unspecified service or procedure codes to

provide services which are not a Medicaid benefit. Submit documentation for these codes with the claim for prepayment review. Documentation should include medical records, such as the operative report, patient history, physical examination report, pathology report, and discharge summary, which provide

enough information to identify the procedure performed and to support medical necessity of the procedure.

Unlisted procedures require manual review and often manual pricing. During review of medical record information, medical staff will determine payment based on reimbursement for similar procedures. Additional reimbursement may be considered only when care above similar standard procedures is medically necessary. Additional payment will not be considered when procedures are considered investigational or cosmetic.

Manual Review – Process, Criteria, and Actions

The manual review process is reserved for specific types of cases as described below. Do not submit the claim for manual review if the denial does not fit the criteria below; refer to the tools provided on Utah Medicaid website: https://medicaid.utah.gov.

The Utah Medicaid website also has access to the referenced resources and further information on:

x Coverage and Reimbursement Lookup Tool

x 835 Error Codes List

x Forms (includes the Documentation Submission Form)

Throughout this section, supporting documentation consists of medical records that give evidence and support that the claim is correct.

1. Receive the explanation of benefits (EOB) with a denial of all or part of the claim.

2. Note the codes on the non-paid lines on the EOB in this order:

a. Line Detail Adjustments (adjustments)

b. Line Detail Remarks (remarks)

Note: Always use the “adjustments” and “remarks” together to determine the required

action.

3. IF the adjustment is CO 16 (Claim/service lacks information which is needed for adjudication) AND the remark is N29 (Missing documentation/orders/notes/summary/report/chart)

THEN go to step 6. The claim meets criteria for manual review.

4. If any other adjustment or remark code is used, go to the home page of the Utah Medicaid

website and select the “835 Error Codes List.”

5. On the Error Codes List:

a. Match the codes for the Line Detail Adjustments and Line Detail Remarks with the applicable Adjustment Reason Code Description and Remark Code Description.

b. Go to the Criteria section or step 6, based on these descriptions.

Note: If unable to determine the denial reason, contact Medicaid Customer Service.

Additional Criteria to Determine if the Denial is Eligible for Manual Review

A Modifier is used in a Claim

Modifier 22, 62, or 91

Manual Review is always required for these modifiers. They are flagged by the edit program.

x Modifier 22 – Submit documentation supporting additional time and work required.

x Modifier 62 – Submit claims operative reports from both providers documentation supporting the claim that each surgeon performed separate portions of the procedure(s) that were not those performed by an assistant surgeon.

x Modifier 91 – Submit documentation supporting the claim that separate services were provided for a distinct medical purpose.

Note: Modifier 91 is typically used for laboratory tests. Acceptable use example: A blood culture is repeated to confirm the presence of the organism in the blood. This modifier is not covered when the code is used to repeat a test for quality control purposes.

Modifier 24, 59, 76, or 77

x Modifier 24 can be used for anesthesia pain management services and qualifies for manual review.

o Submit documentation showing when the epidural or block injection is given relative to the general anesthesia.

x Modifier 59 is reviewed when the CPT code posts an incidental or mutually exclusive edit to the primary procedure.

o Submit documentation showing that the procedure is not a component of another procedure, but is a distinct, independent procedure.

Mutually exclusive edits occur when two or more procedures that are usually not performed

during the same patient encounter on the same date of service. The less clinically intense procedure(s) is denied.

Incidental edits occur when relatively minor procedures are performed at the same time as complex primary procedures, and are considered clinically integral to the performance of the primary procedure.

x Modifier 76 or 77

When an edit posts that the claim is an exact duplicate of a paid claim, the claim is only manually reviewed when submitted with a 77 or 76 on the denied line.

o Submit documentation supporting the rational for a repeated procedure or service by the same or another provider.

Codes That Always Require Manual Review

Medicaid policy requires some codes always require manual review.

x “Unlisted” CPT codes require manual review. When an unlisted code is denied:

 Verify the unlisted code is the most accurate and appropriate.

o If it is not the most accurate and appropriate code, recode and resubmit the claim.

^{o If the code is the most accurate and appropriate for the}

procedure, submit documentation supporting the use of the code.

x Codes that deny for “No Prior Authorization” that actually require manual review. These codes require manual review, but can only be flagged in the system by indicating prior authorization is required.

 A claim denied for “Diagnosis requires a prior authorization” requires manual

_review.

o To expedite review, submit supporting documentation.

 CPT code 77300 has a 4 unit limit. When billed for 5 or more units, it will be

denied for “Prior Authorization”, but it actually requires manual review.

^{o To expedite review, submit supporting documentation.}

6. If the claim meets the criteria for review, submit the following documentation to the applicable

FAX number on the Documentation Submission Form:

x Completed Documentation Submission Form.

x Appropriate documentation to support the claim/code under review.

9 - 2 Non-Covered Procedures

Generally, Medicaid does not reimburse non-covered procedures. However, exceptions may be considered through the prior authorization process in the circumstances listed below and when no code that is a Medicaid benefit accurately describes the service to be provided:

1. The patient is a child under 21 years of age. Because of the patient’s age, the Child Health Evaluation and Care Program (CHEC) may pay for services which are medically necessary but not typically covered by Medicaid. The CHEC program is based on a preventive health philosophy of discovering and treating health problems before they become disabling and therefore more costly to treat in terms of both human and financial resources. Please refer to SECTION 2, CHEC SERVICES, for additional information. For your convenience, the PA requirements for CHEC services are listed in the Chapter 9 - 3, Prior Authorization Criteria.

2. Reconstructive procedures following disfigurement caused by trauma or medically necessary surgery.

3. Reconstructive procedures to correct serious functional impairments (for example, inability to swallow).

4. When performing the procedure is more cost effective for the Medicaid Program than other alternatives.