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Administrative Policy 32—Billing and Reimbursement Guidelines for Increased Procedural Services Effective May 15, 2020

Audience: Physicians and Ancillary Providers

Univera Healthcare is implementing the following administrative policy effective May 15, 2020, to define the billing and reimbursement guidelines for increased procedural services (i.e., modifier 22) billed on professional claims. This policy is in line with Centers for Medicare & Medicaid Services and Current Procedural Terminology (CPT) guidelines.

The new policy will apply to all practitioners and the following business lines: Commercial (HMO, PPO, POS, ASO/ASC and Indemnity), Medicare Advantage, New York State Government Programs (Medicaid Managed Care, Health and Recovery Plan, Child Health Plus and Special Programs (Healthy New York and Essential Plan).

Administrative Policy 32 – Increased Procedural Services:

  • Claims for services billed with a modifier 22 are reviewed and approved by a Health Plan medical director. The Health Plan will reimburse codes reported with, and approved for, modifier 22, at 118 percent of the applicable fee schedule.

  • Services billed with Modifier 22 that are not approved by a Health Plan medical director or were not submitted with medical records to support the increased procedural service billed, will be reimbursed at the applicable standard fee schedule.

  • Reimbursement for increased procedural services requires documentation that details the specific increased work and complexity that necessitated the use of modifier 22.

  • This policy will be reviewed pre-payment. Pre-payment review means claims are reviewed prior to payment. A pre-payment review results in an initial determination. Post-payment review means that claims are reviewed after adjudication. A post-payment review may result in either no change to the initial determination or a revised determination.

These services are subject to audit and policy updates at Univera Healthcare’s discretion. Members are held harmless for all denials resulting from this Administrative Policy.  You can access the individual policies on our website, UniveraHealthcare.com/Adminpol. Note: You must login with your username and password to access our administrative policies.

If you are not currently registered to view the secure section of our website, we encourage you to register today at Provider.UniveraHealthcare.com

If you need assistance registering, contact the Web Security Help Desk at 1-800-278-1247. In addition, your Provider Relations representative is available to assist with website registration and functionality training.

 
 
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