New and Updated Payment Policies - Effective September 1, 2023
MHS Health Wisconsin continually reviews and updates our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members.
The following policies will take effect on September 1, 2023. The complete policies will also be posted on the Clinical and Payment Policies page on the same day.
Lines of Business
Based on CMS guidelines, bill type ending in XX2 or XX3 will be denied when discharge status 30 is not present on the claim.
Inappropriate Primary Diagnosis
Deny or limit diagnosis codes based upon correct coding guidelines that are supported by CMS and ICD-10. Based on these guidelines, claims will deny when billed with unacceptable primary/principal diagnosis, manifestation diagnosis, and sequela diagnosis in outpatient or inpatient facilities.
High Dollar IV Hydration
Requesting medical records to determine if documentation supports services billed and that those services were in accordance with policies and regulations related to IV hydration therapy.
Custom Fitted or Custom Fabricated Prosthetics or Orthotics
Requesting medical records to verify documentation supports high-dollar custom DME codes billed by the provider
Optum CPI AMISYS – Phase 2
To identify surgical claims that have a 10- or 90-day global period, and no modifier 54 present, which were performed in a POS 23 (emergency room), where follow up would not typically occur. Patients are typically referred to their PCP for follow up. Review will take place to ensure that the entire surgical package was performed by the billing provider.
Professional Claims for Select Surgical Procedures
Pre-payment medical record review for inappropriate billing of services not documented in the physician clinical notes. There is no medical necessity decision making involved.
Facility NCCI Modifier Override
The algorithm identifies instances in which providers submit claims that utilize the NCCI bypass modifiers with CPT codes that are not allowed to be billed together for the same recipient, on same date of service, based on Medicare NCCI OCE edits.
Thank you for being a valued partner in caring for the health and well-being of our members. If you have any questions about the policies listed above or any our Clinical & Payment Policies, please contact your Provider Relations representative or call the Provider Inquiry Line at 1-800-222-9831. If you are unsure who your representative is, please email us at WI_Provider_Relations@mhswi.com.