Payment Integrity Policies

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Medicaid Payment Integrity Payment Policies

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Policy Number Policy Name Effective Date Service Area Policy Type Link
13 ADD-ON Code 11/01/2020 Outpatient Coding Payment Policy View Policy
99 Advance Beneficiary Notice (ABN) Modifiers GA, GX, GY and GZ 1/4/2024 Outpatient Billing Payment Policy View Policy
54 After Hours and Weekend Care Professional 8/1/2023 Professional Coding Payment Policy View Policy
14 Ambulance Modifier Coding Policy 11/01/2020 Professional Coding Payment Policy View Policy
34 Appropriate Level of Care Reimbursement 01/07/2022 Outpatient/Inpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
102 BRCA1 and BRCA2 Genetic Testing 01/04/2024 Professional/Labs Billing Payment Policy View Policy
35 Breast Cancer Genetic Testing Tier 1 vs Tier 2 01/04/2023 Professional/Labs Billing Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
42 Corrected Claims 10/21/2022 Professional/Labs/Inpatient/Outpatient Billing Payment Policy View Policy
53 Co Surgeon Team Surgeon Professional 09/01/2023 Professional Coding Payment Policy View Policy
38 Critical Care Codes when Discharging Home from the Emergency Department 08/04/2022 Professional Clinical Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
16 Decision for Surgery Modifier 57 Coding Policy 11/01/2020 Professional Clinical Payment Policy View Policy
2 Diagnosis Code Coding Policy 11/01/2020 Professional Coding Payment Policy View Policy
59 Discontinued Procedures 04/06/2023 Professional/Labs/Inpatient/Outpatient Coding Payment Policy View Policy
65 DME KF Modifier 08/01/2023 DME Professional Services Coding Payment Policy View Policy
23 DME Place of Service separately reimbursable 09/11/2023 DME Professional Services Billing Payment Policy View Policy
24 DME Rental Vs Purchase 12/01/2023 DME Professional Services Clinical Payment Policy View Policy
25 DRG Clinical Validation 01/07/2022 Inpatient Billing Payment Policy View Policy
45 Duplicate Claims 11/01/2022 Professional Billing Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
24 Excludes 1 Note 11/01/2020 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
39 Facility Emergency Department Evaluation and Management leveling 08/15/2022 Facility Coding Payment Policy View Policy
80 Fee Schedule 09/01/2023 Professional/Outpatient Billing Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
0 General Coding Policy 11/01/2020 Professional Coding Payment Policy View Policy
51 Global Surgical Packages for Professional Providers 09/01/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
56 High Dollar Pharmacy 08/01/2023 Pharmacy Billing Payment Policy View Policy
37 High Level Evalution and Managment with Preventive Medicine 10/18/2022 Professional Coding Payment Policy View Policy
48 Hospice Value Code 61 01/01/2023 Professional Coding Payment Policy View Policy
70 Hospice 10/19/2023 Professional Clinical Payment Policy View Policy
01 Hospital Routine Supplies Services 12/01/2017 Inpatient Billing Payment Policy View Policy
36 Hydrolyzed Enteral Formula Diagnosis 01/01/2023 Professional Clinical/Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
20 ICD-10 First Listed Diagnosis Coding Policy 11/01/2020 Professional Coding Payment Policy View Policy
3 ICD-10 Specificity Coding Policy 11/01/2020 Professional Coding Payment Policy View Policy
18 Image Guided Radiation Therapy Coding Policy 11/01/2020 Professional Clinical Payment Policy View Policy
71 Inpatient services billed on Outpatient bill types 09/01/2023 Outpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
4 Lab Codes with Modifiers 59 and 91 11/01/2020 Modifier/Professional Coding Policy View Policy
17 Lab Panel 11/01/2020 Labs Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
15 Medically Unlikely Edits 11/01/2020 Professional/Outpatient Coding Payment Policy View Policy
5 Modifer 26 11/01/2020 Modifier/Professional Coding Payment Policy View Policy
6 Modifier KX 11/01/2020 Modifier/Professional Coding Payment Policy View Policy
7 Modifier TC 11/01/2020 Modifier/Professional Coding Payment Policy View Policy
66 Molina Healthcare Billing Requirements 06/01/2023 Professional Billing Payment Policy View Policy
67 Multiple EM codes for the same provider same date of service 09/01/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
32 Newborn and NICU 01/07/2022 Inpatient Billing Payment Policy View Policy
12 NCCI PTP with Modifiers 11/01/2020 Modifier/Professional Coding Payment Policy View Policy
19 Non-Invasive Prenatal Testing 11/01/2020 Professional Clinical Payment Policy View Policy
44 NDC 11/01/2022 Professional/Outpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
50 Observation 06/01/2023 Professional/outpatient Clinical Payment Policy View Policy
33 Outpatient Definitive Drug Testing 09/01/2021 Outpatient Billing Payment Policy View Policy
84 Overlapping Room and Board 09/25/2023 Professional Billing Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
10 Packaged and conditionally packaged lab services Coding Policy 11/01/2020 Outpatient Billing Payment Policy View Policy
106 Physician Office Laboratory Testing 10/18/2022 Labs Coding Payment Policy View Policy
104 Polysomnography Studies and Home Sleep Testing 09/25/2023 Professional Clinical Payment Policy View Policy
00 Post Pay General Policy 06/01/2023 Professional Billing Payment Policy View Policy
48 Post-Pay Authorization Audit 06/01/2023 Professional/Labs/Inpatient/Outpatient Billing Payment Policy View Policy
47 Psychotherapy Add On with High Level EM 10/18/2022 Professional Coding Payment Policy View Policy
105 PT/OT Initial Evaluations 09/25/2023 Professional Clinical Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
41 Readmission 06/01/2023 Inpatient Payment Policy View Policy
60 Reduced Services and Discontinued Procedures 07/10/2023 Professional Coding/Payment Policy View Policy
Repeat Procedure Modifiers 76 & 77 Modifier/Professional Coding Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
26 Sepsis 01/07/2022 Inpatient Coding Payment Policy View Policy
46 Split-Night-Sleep-Study 10/18/2022 Professional Coding Payment Policy View Policy
92 Status Indicator Flag B Bundled Codes 09/25/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
10 Therapy Modifier Coding Policy 11/01/2020 Modifier/Outpatient Coding Payment Policy View Policy
82 Tendon Injections Missing Diagnosis 09/01/2023 Professional Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
61 Unspecified Codes in an Inpatient Setting Policy 04/01/2022 Inpatient Coding Payment Policy View Policy
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link
Policy Number Policy Name Effective Date Service Area Policy Type Link