UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
West Virginia Reimbursement Policies
Table of Contents
Administration
Claims Requiring Additional Documentation
Claims Submission - Required Information for Facilities
Claims Submission - Required Information for Professional Providers
Claims Timely Filing: Participating and Nonparticipating
Code and Clinical Editing Guidelines
Documentation Standards for Episodes of Care
Duplicate or Subsequent Services on Same Date of Service
Eligible Charges
Emergency Services: Nonparticipating Providers and Facilities
Inpatient Facility Transfers
Inpatient Readmissions
Locum Tenens Physicians
Other Provider Preventable Conditions
Present on Admission Indicator for Health Care-Acquired Conditions
Requirements for Documentation of Proof of Timely Filing
Reimbursements for Items under Warranty
Reimbursements of Claims with Charge Discrepancies
Reimbursement of Sanctioned and Opt-Out Providers
Scope of Practice
Site of Service Payment Differential - Professionals
4
7
10
13
15
18
21
24
26
29
31
33
35
37
40
43
45
47
49
51
Anesthesia
Professional Anesthesia Services
53
Coding
Assistant at Surgery (Modifiers 80/81/82/AS)
Diagnoses Used in DRG Computation
Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
57
59
61
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
July 2015
Modifier 22: Increased Procedural Services
Modifier 24: Unrelated Evaluation and Management Services by the Same Physician
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service
Modifier 57: Decision for Surgery
Modifier 62: Co-Surgeons
Modifier 63: Procedures Performed on Infants less 4kg
Modifier 66: Surgical Teams
Modifier 76: Repeat Procedure by the Same Physician
Modifier 77: Repeat Procedure by Another Physician
Modifier 78: Unplanned Return to the Operating/Procedure Room
Modifier 91: Repeat Clinical Diagnostic Laboratory Test
Modifier LT and RT: Left Side/Right Side Procedures
Modifier Usage
Multiple Bilateral Surgery: Professional and Facility Reimbursement
Reimbursement for Reduced and Discontinued Services
Reimbursement of Services with Obsolete Codes
Robotic Assisted Surgery
Split-Care Surgical Modifiers
Unlisted or Misc. Codes (aka Dump Codes)
64
66
68
70
75
77
80
83
85
88
91
93
95
98
101
104
106
108
111
Drugs
Drug and Injectable Limits
Facility Take-Home Drugs
113
115
Evaluation and Management
Consultations
Physician Standby Services
Preventive Medicine and Sick Visits on the Same Day
117
122
124
Facilities
Preadmission Services for Inpatient Stays
126
Prevention
Early and Periodic Screening, Diagnostic Treatment
129
Vaccines for Children Program
131
Prosthetics & Orthotic
Prosthetic and Orthotic Devices
135
Radiology
Portable/Mobile/Handheld Radiology Services
138
Surgery
Abortion
Global Surgical Package for Professional Providers
Hysterectomy
Maternity Services
Sterilization
141
143
147
150
152
Transportation
Transportation Services: Ambulance and Nonemergent Transport
155
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Claims Requiring Additional Documentation
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
Professional providers and facilities are required to submit additional
documentation for adjudication of applicable types of claims. If the
required documentation is not submitted, the claim may be denied.
Applicable types of claims include:

Upon request, claims for durable medical equipment, prosthetics,
orthotics and supplies (DMEPOS), and home health and
rehabilitation therapies (e.g., physical, occupational, speech)
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0027-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Requiring Additional Documentation
January 2015
Page 5 of 160

Claims with unlisted or miscellaneous codes

Claims for services requiring clinical review (e.g., complicated or
unusual procedures, emergency room services, etc.)

Claims for services found to possibly conflict with covered benefits
to covered persons after validity review of member’s medical
records (e.g., member eligibility)

Claims for services found to possibly conflict with medical
necessity of covered benefits to covered persons (e.g., new
technology, potential experimental or investigational procedures,
devices, potential cosmetic procedures, etc.)

Claims requesting an extension of benefits

Claims being reviewed for potential fraud, abuse or demonstrated
patterns of billing/coding inconsistent with peer benchmarks

Claims for services that require an invoice (e.g., custom DME/
prosthetics that are reimbursed based on purchase price)

Claims for services that require an itemized bill (e.g., stop-loss,
denied inpatient days, carve-out services)

Claims for beneficiaries with other health insurance

Claims requiring documentation of the receipt of an informed
consent form (e.g., sterilization,)

Claims requiring a certificate of medical necessity (e.g., motorized
wheelchairs, lymphedema pumps, oxygen, etc.)

Appealed claims where supporting documentation may be
necessary for determination of payment

Other documentation required by the CMS and state or federal
regulation
UniCare may request additional documentation or notify the provider
or facility of additional documentation required for claims, subject to
contractual obligations. If documentation is not provided following the
request or notification, UniCare may:

Deny the claim, as provider failed to provide required prepayment
documentation.

Recoup monies previously paid on the claim if the provider failed
to provide required documentation for postpayment review.
UniCare is not liable for interest or penalties when payment is denied
or recouped because the provider fails to submit required or requested
documentation.
History

UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Requiring Additional Documentation
January 2015
Page 6 of 160
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies



Claims timely filing
Documentation standards for episodes of care
Unlisted or miscellaneous codes (aka: dump codes)
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Claims Submission – Required Information for Facilities
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
Institutional providers (facilities) are required, unless otherwise stipulated
in their contract, to submit the original CMS 1500/UB92 uniform
institutional provider bill to UniCare for payment of health care services.
Providers must submit a properly completed UB-04/CMS-1450 for
services performed or items/devices provided. If the required information
is not provided, the claim is not considered a clean claim and UniCare can
delay or deny payment without being liable for interest or penalties. The
UB-04/CMS-1450 claim form must include the following information, if
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0028-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Submission – Required Information for Facilities
January 2015
Page 8 of 160
applicable:

Facility information (i.e., name and address)

Bill type

Federal tax ID number (TIN)

Date period the UB-04/CMS-1450 covers

Patient information (i.e., name, subscriber number, address, date of
birth, gender and marital status)

Admission date and type

Admission hour for inpatient services only

Point of origin for admission or visit

Discharge hour for inpatient services only

Patient discharge status code

Condition code(s)

Accident state, if applicable

Occurrence code(s) and date(s)

Occurrence span code(s) and date(s)

Revenue code(s) and description(s) and applicable corresponding
CPT/HCPCS codes, if necessary. Applicable claims billed only with
the revenue code will be denied. Providers will be asked to resubmit
with the correct CPT/HCPCS code in conjunction with the applicable
revenue code

Date(s), unit(s) and total charge(s) of service(s) rendered

Insurance payer’s information (i.e., name, provider number and
coordination of benefits secondary and tertiary payer information)

Prior payments – payers, if applicable

Insured’s information (i.e., name, relationship to patient, member ID
number, insurance group name and number, date of birth, employer
name and location)

Principal, admitting and other ICD-9 diagnosis codes, including 4th
and 5th digit when required

Present on admission (POA) indicator, as applicable

Code (ICD-9 procedure) and date of principal procedure for inpatient
services, if applicable

National provider identifier state Medicaid provider number (in
accordance with the applicable state requirements)

Encounter reporting data elements in accordance with applicable state
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Submission – Required Information for Facilities
January 2015
Page 9 of 160
compliance requirements, including:
o Admission source code
o Applicable value code for billed admission type code
o Birth weight with applicable value and admission type codes
o Facility type code
o National drug code(s) (NDC) to include the NDC number, unit
price, quantity and composite measure per drug
UniCare cannot accept claims with alterations to billing information (e.g.,
using correction fluid/tape, crossing out or writing over mistakes). Claims
that have been altered will be returned to the provider with an explanation
of the reason for the return.
Although UniCare prefers the submission of claims electronically through
the electronic data interchange, UniCare will accept paper claims. A paper
claim must be submitted on an original claim form with dropout red ink,
computer-printed or typed, in a large, dark font in order to be read by
optical character reading technology. All claims must be legible. If any
field on the claim is illegible, the claim will be rejected or denied.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies





Acceptance of altered claim forms
Claims requiring additional documentation
Claims submission — Required information for professional providers
Other provider preventable conditions (OPPC)
Present on admission indicator for health-care acquired conditions
Related materials

UniCare electronic data interchange manual
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Claims Submission – Required Information for Professional Providers
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Professional providers of health care services are required, unless
otherwise stipulated in their contract, to submit an original CMS-1500
health insurance claim form to UniCare for payment of health care
services.
Policy
Providers must submit a properly completed CMS-1500 for services
performed or items/devices provided. If the required information is not
submitted, the claim is not considered a clean claim, and UniCare will
deny payment without being liable for interest or penalties. The
CMS-1500 claim form must include the following information, if
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0029-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Submission – Required Information for Professional Providers
January 2015
Page 11 of 160
applicable:

Patient information (i.e., name, address, date of birth, gender,
relationship to insured, medical condition as related to employment or
an accident, marital status, employment and student status)

Insured’s information (i.e., member ID number, subscriber number,
name, address including ZIP code, telephone number, policy group or
FECA number, date of birth, name of employer or school, name of
insurance plan or program and name of other health benefit plan)

Coordination of benefits/other insured’s information (i.e., name, date
of birth, policy or group number, name of employer or school and
name of insurance plan or program)

Name of referring physician or source

Indication of outside laboratory

ICD-9 diagnosis code(s), including 4th and 5th digit when required

Clinical Laboratory Improvement Act certification number

Date(s) of service(s) rendered

Place of service/location code(s)

Description of services rendered using CPT-4 codes/HCPCS codes
and appropriate modifiers

Charge(s) for service(s) rendered

Day(s) or unit(s) related to service(s) rendered

Total charges, amount paid by patient (i.e., copay), and balance due

Federal tax ID number

Name and address of facility where services were rendered and the
NPI of the service facility, if applicable

National provider identifier:
o Individual servicing provider’s NPI must be reported as the
rendering provider ID, if applicable
o When billing is from a group, the group’s NPI must be reported as
the billing provider, if applicable

Remittance information (i.e., name, address, telephone)

Indication of signature on file or a handwritten or computer generated
signature for the provider of service or his/her representative and date
the form was signed

National drug code(s) (NDC) to include the NDC number, unit price,
quantity and composite measure per drug

State Medicaid provider number as required by state regulation (in
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Submission – Required Information for Professional Providers
January 2015
Page 12 of 160
accordance with the applicable state requirements)
UniCare cannot accept claims with alterations to billing information (e.g.,
using correction fluid/tape, crossing out or writing over mistakes). Altered
claims will be returned to the provider with an explanation of the reason
for the return.
Although UniCare prefers the submission of claims electronically through
the electronic data interchange, UniCare will accept paper claims. A paper
claim must be submitted on an original claim form with drop out red ink,
computer-printed or typed, in a large, dark font in order to be read by
optical character reading technology. All claims must be legible. If any
field on the claim is illegible, the claim will be rejected or denied.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies





Acceptance of altered claim forms
Claims requiring additional documentation
Claims submission — Required information for facilities
Modifier usage
Other provider preventable conditions
Related materials

UniCare electronic data interchange manual
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Claims Timely Filing: Participating and Nonparticipating
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of claims for covered services for
covered members in compliance with federal and/or state mandates
regarding claims timely filing requirements. UniCare follows the
standard of 12 months for participating and nonparticipating providers
and facilities.
Timely filing is determined by subtracting the date of service from the
date UniCare receives the claim and comparing the number of days to
the applicable federal or state mandate. If there is no applicable federal
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0030-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Claims Timely Filing: Participating and Nonparticipating
January 2015
Page 14 of 160
or state mandate, then the number of days is compared to the company
standard. If services are rendered on consecutive days, such as for a
hospital confinement, the limit will be counted from the last day of
service. Limits are based on calendar days unless otherwise specified.
If the member has other health insurance that is primary, then timely
filing is counted from the date of the explanation of payment (EOP) of
the other carrier.
Providers resubmitting paper claims for corrections must clearly mark
the claim Corrected Claim. Corrected claims submitted electronically
must have the applicable frequency code. Failure to mark the claim
appropriately may result in denial of the claim as a duplicate. Corrected
claims must be received within the applicable timely filing
requirements of the originally submitted claim due to the original claim
not being considered a clean claim.
Claims filed beyond federal or state-mandated, or UniCare standard
timely filing limits will be denied as outside the timely filing limit.
Services denied for failure to meet timely filing requirements are not
subject to reimbursement unless the provider presents documentation
proving a clean claim was filed within the applicable filing limit.
UniCare reserves the right to waive timely filing requirements on a
temporary basis following documented natural disasters or under
applicable state guidance.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies


Eligible charges
Requirements for documentation of proof of timely filing
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Code and Clinical Editing Guidelines
Effective Date: TBD
Committee Approval Obtained: TBD
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare applies code and clinical editing guidelines (CCEG) to evaluate
claims for accuracy and adherence to nationally accepted industry
standards and plan benefits unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise.
UniCare uses software products that ensure compliance with standard
code edits and rules. These products increase consistency of payment for
providers by ensuring correct coding and billing practices are followed.
CCEG consists of the following measures, including but not limited to:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0031-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Code and Clinical Editing Guidelines
January 2015
Page 16 of 160

Code editing software, CMS National Correct Coding Initiative edits
and outpatient code edits

Clinical criteria

Licensed clinical medical review

Claims processing platform
Per state requirements, UniCare publishes its use of specific commercial
code editing software. UniCare only customizes applicable CCEG
measures due to compelling business reasons.
CCEG measures are updated as applicable and as needed to incorporate
new codes, code definition changes and edit rule changes. All claims
submitted after the configuration implementation date, regardless of
service date, will be processed according to up-to-date CCEG measures.
No retrospective payment changes, adjustments, and/or requests for
refunds will be made when processing changes are a result of new code
editing rules within a module update. The member is not responsible and
should not be balance billed for any procedures for which payment has
been denied or reduced as the result of CCEG measures.
UniCare uses CCEG to analyze outpatient services, including those that
are considered:

Rebundled or unbundled services

Mutually exclusive services

Incidental procedures or items

Inappropriately billed visits

Diagnosis to procedure mismatch

Upcoded services
Other procedures and categories that are reviewed include:

Cosmetic procedures

Obsolete or unlisted procedures

Age/gender mismatch procedures

Investigational or experimental procedures

Procedure eligibility (e.g., assistant at surgery, co-surgeons, surgical
teams, multiple fee reductions, etc.)

Procedures billed with inappropriate modifiers
UniCare does not allow reimbursement for services, procedures, items,
etc., that conflict with CCEG.
History

UniCare review approved and effective TBD
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Code and Clinical Editing Guidelines
January 2015
Page 17 of 160
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies

None
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Documentation Standards for Episodes of Care
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare requires that upon request for clinical documentation to
support claims payment for services, the provided information should:
Policy

Identify the member

Be legible

Reflect all aspects of care
To be considered complete, documentation for episodes of care will
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0034-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Documentation Standards for Episodes of Care
January 2015
Page 19 of 160
include, at a minimum, the following elements:

Patient identifying information

Consent forms

Health history, including applicable drug allergies

Physical examinations

Diagnoses and treatment plans for individual episodes of care

Physician orders

Face-to-face evaluations, when applicable

Progress notes

Referrals, when applicable

Consultation reports, when applicable

Laboratory reports, when applicable

Imaging reports (including X-ray), when applicable

Surgical reports, when applicable

Admission and discharge dates and instructions, when applicable

Preventive services provided or offered, appropriate to member’s
age and health status

Evidence of coordination of care between primary and specialty
physicians, when applicable

Working diagnoses consistent with findings and test results

Treatment plans consistent with diagnoses
Providers should refer to standard data elements to be included for
specific episodes of care as established by The Joint Commission,
formerly the Joint Commission on Accreditation of Healthcare
Organizations. A single episode of care refers to continuous care or a
series of intervals of brief separations from care to a member by a
provider or facility for the same specific medical problem or condition.
Documentation for all episodes of care must meet the following
criteria:

Legible to someone other than the writer

Information identifying the member must be included on each page
in the medical record

Each entry in the medical record must be dated and include author
identification, which may be a handwritten signature, unique
electronic identifier or initials
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Documentation Standards for Episodes of Care
January 2015
Page 20 of 160
Other documentation not directly related to the member
Other documentation not directly related to the member, but relevant to
support clinical practice, may be used to support documentation
regarding episodes of care, including:

Policies, procedures and protocols

Critical incident/occupational health and safety reports

Statistical and research data

Clinical assessments

Published reports/data
UniCare may request that providers submit additional documentation,
including medical records or other documentation not directly related
to the member, to support claims submitted by the provider. If
documentation is not provided following the request or notification, or
if documentation does not support the services billed for the episode of
care, UniCare may:

Deny the claim

Recover and/or recoup monies previously paid on the claim
UniCare is not liable for interest or penalties when payment is denied
or recouped because the provider fails to submit required or requested
documentation.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 The Joint Commission standards
Definitions

General Reimbursement Policy Definitions



Claims requiring additional documentation
Claims submission – Required information for facilities
Claims submission – Required information for professional
providers

None
Related policies
Related materials
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Duplicate or Subsequent Services on the Same Date of Service
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of a duplicate or subsequent service
provided on the same date of service if billed with an appropriate
modifier or with additional units, as applicable within benefit limits
unless otherwise noted by provider, state, federal or CMS contracts
and/or requirements.
Reimbursement of a duplicate or subsequent service
Reimbursement of duplicate or subsequent services is based on the
correct usage of the modifiers below that indicate the service was
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0036-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service
January 2015
Page 22 of 160
appropriately repeated or additionally billed for the same member:

Modifier 62: Co-surgeons

Modifier 66: Surgical teams


Modifier 76: Repeat procedure by the same physician
Modifier 77: Repeat procedure by another physician

Modifier 80: Assistant at surgery providing full assistance to the
primary surgeon

Modifier 81: Assistant at surgery providing minimal assistance to
the primary surgeon

Modifier 82: Assistant at surgery, when a qualified resident
surgeon is not available to assist the primary surgeon

Modifier AS: Assistant at surgery who is a nonphysician (e.g.,
physician assistant, nurse practitioner)

Modifier 91: Repeat clinical diagnostic laboratory test

Modifier GG: Performance and payment of a screening
mammogram and diagnostic mammogram on the same patient,
same day

Modifier GH: Diagnostic mammogram converted from screening
mammogram on same day
UniCare may deny a duplicate or subsequent service provided on the
same date of service billed on the same or separate claims unless billed
with an appropriate modifier.
UniCare will review claims billed with suspected duplicate or
subsequent services. Claims will be denied for services determined to
be duplicate or subsequent claims without the appropriate modifier.
Reimbursement of bundled services
When a service is unbundled from a more complex or comprehensive
service and billed individually on the same date of service as the more
comprehensive service:

The claim line for the individual service will be denied through
code editing if billed on the same claim.

The claim will be reviewed if billed on separate claims.
The following modifiers indicate an individual service is distinct and
separate from the more comprehensive service:

Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service

Modifier 59: Distinct procedural service
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Duplicate or Subsequent Services on the Same Date of Service
January 2015
Page 23 of 160
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract

Definitions





Related policies
Related materials
UniCare review approved and effective 03/01/15
Duplicate Services:
A service is considered a definite duplicate if some or all of the
following elements on the claim match:
o Member
o Date of service
o Charge amount
o Provider of service
o Type of service, based on procedure or revenue codes used
A service is suspected duplicate if the following elements on the
claim match:
o Member
o Procedure code
o Date of service
Subsequent Service: For purposes of this policy, it is a medically
necessary service that is performed or provided for the same
member more than once on the same date of service
General Reimbursement Policy Definitions







Assistant at surgery (Modifiers 80/81/82/AS)
Code and clinical editing guidelines
Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier 59: Distinct procedural service
Modifier 62: Co-surgeons
Modifier 66: Surgical teams
Modifier 76: Repeat procedure by the same physician
Modifier 77: Repeat procedure by another physician
Modifier 91: Repeat clinical diagnostic laboratory test
Modifier usage

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Eligible Charges
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of eligible charges unless provider,
state, federal or CMS contracts and/or requirements indicate otherwise.
Eligible charges are those charges billed by the provider subject to
conditions and requirements which make the service eligible for
reimbursement.
Eligibility for reimbursement of the service is dependent upon
application of the following conditions and requirements:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0037-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Eligible Charges
January 2015
Page 25 of 160

Member program eligibility

Provider program eligibility

Benefit coverage

Authorization requirements

Provider manual guidelines

UniCare administrative policies

UniCare clinical policies

UniCare reimbursement policies

Code editing logic
The allowed amount reimbursed for the eligible charge is based on the
applicable fee schedule or contracted/negotiated rate after application
of coinsurance, copayments, deductibles and coordination of benefits.
UniCare will not reimburse providers for:

Items the provider receives free of charge.

Items the provider provides to the member free of charge.
In the absence of clear language or specific reference to eligible
charges in provider contracts, the use of the following terms will
default to eligible charges as stated within this policy:

Billed charges

Covered charges

Billed charges for covered services

Allowed charges

Percent of charge
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 National Association of Insurance Commissioners (NAIC) Model
Regulation, 2013
Definitions

General Reimbursement Policy Definitions

Claims submission – Required information for professional
providers

None
Related policies
Related materials
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Emergency Services: Nonparticipating Providers and Facilities
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for emergency services provided by
nonparticipating providers and facilities unless provider, state, federal
or CMS contracts and/or requirements indicate otherwise. Unless
otherwise required by federal and/or state regulation or contract,
reimbursement is based on no more than:

Medicaid product lines only: The amount that would have been
reimbursed to the provider by the beneficiary’s state fee-for-service
Medicaid program
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0039-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Emergency Services: Nonparticipating Providers and Facilities
January 2015
Page 27 of 160

All other product lines: The applicable out-of-network emergency
rate for nonparticipating providers and facilities
UniCare adheres to the requirements of the Emergency Medical
Treatment and Labor Act (EMTALA) and the Federal Medicaid
Managed Care Regulations.
UniCare will act in accordance with the Deficit Reduction Act (DRA)
of 2005, Section 6085, with an effective date of January 1, 2007, that
states:
“Any provider of emergency services that does not have in effect a
contract with a Medicaid managed care entity that establishes payment
amounts for services furnished to a beneficiary enrolled in the entity’s
Medicaid managed care plan must accept as payment in full no more
than the amounts (less any payments for indirect costs of medical
education and direct costs of graduate medical education) that it could
collect if the beneficiary received medical assistance under this title
other than through enrollment in such an entity. In a State where rates
paid to hospitals under the State plan are negotiated by contract and not
publicly released, the payment amount applicable under this
subparagraph shall be the average contract rate that would apply under
the State plan for general acute care hospitals or the average contract
rate that would apply under such plan for tertiary hospitals.”
UniCare shall develop and maintain a record, pursuant to DRA
stipulations, for West Virginia’s payment methodology according to its
FFS Medicaid program. DRA applicability will apply to the Medicaid
product line.
UniCare will not limit consideration of reimbursement for emergency
services on the basis of lists of diagnoses or symptoms; however,
additional medical record documentation may be required in order to
clearly identify and determine appropriate reimbursement of
emergency services.
Claims for emergency services are subject to UniCare’s eligible
charges, code and clinical editing and claims requiring additional
documentation policies.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Deficit Reduction Act of 2005 (Pub.L. No. 109-171)
 Emergency Medical Treatment and Labor Act (EMTALA)
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Emergency Services: Nonparticipating Providers and Facilities
January 2015
Page 28 of 160
Definitions
Related policies
Related materials

General Reimbursement Policy Definitions





Claims requiring additional documentation
Claims submissions - Required information for facilities
Claims submissions - Required information for professional
providers
Code and clinical editing
Eligible charges

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Inpatient Facility Transfers
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows payment for services rendered by both the sending and
the receiving facility when a patient is admitted to one acute care
facility and subsequently transferred to another acute care facility for
the same episode of care, in compliance with federal and/or state
guidelines regarding facility transfers payment. UniCare will use the
following criteria:

Transferring facility will receive a calculated per diem rate based
on length of stay not to exceed the amount that would have been
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0043-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Inpatient Facility Transfers
January 2015
Page 30 of 160
paid if the patient had been discharged to another setting.

Receiving facility will receive full diagnosis related group (DRG)
payment.
This policy only affects those facilities reimbursed for inpatient
services by a DRG methodology.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies






Diagnoses used in DRG computation
Documentation standards for episodes of care
Inpatient readmissions
Other provider preventable conditions
Present on admission facility acquired conditions
Transportation services
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Inpatient Readmissions
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow separate reimbursement for claims that have
been identified as a readmission to the same hospital for the same,
similar, or related condition unless provider, state, federal, or CMS
contracts and/or requirements indicate otherwise. In the absence of
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0044-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Inpatient Readmissions
January 2015
Page 32 of 160
federal, state and/or contract mandates, UniCare will use the following
standards:

Readmission up to seven days from discharge

Same or related diagnoses related group (DRG)
Readmissions occurring on the same day for symptoms related to, or
for evaluation and management of, the prior stay’s medical condition
are considered part of the original admission and will be combined.
UniCare considers a readmission to the same hospital for the same,
similar or related condition on the same date of service to be a
continuation of initial treatment.
UniCare reserves the right to recoup and/or recover monies previously
paid on a claim that falls within the guidelines of a readmission for a
same, similar or related condition as defined above.
Exclusions

Admissions for the medical treatment of cancer, primary
psychiatric disease and rehabilitation care

Planned readmissions

Patient transfers from one acute care hospital to another

Patient discharged from the hospital against medical advice
This policy only affects those facilities reimbursed for inpatient
services by a DRG methodology.
History

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
References and
research materials



CMS
State Medicaid
State contract
Definitions

General Reimbursement Policy Definitions
Related policies




Diagnoses used in DRG computation
Documentation standards for episodes of care
Other provider preventable conditions
Present on admission hospital acquired conditions
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Locum Tenens Physicians
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of locum tenens physicians in
accordance with CMS guidelines unless provider, state or federal
contracts and/or requirements indicate otherwise.
Policy
UniCare will reimburse the member’s regular physician or medical
group for all covered services (including emergency visits) provided by
a locum tenens physician during the absence of the regular physician,
in cases where the regular physician pays the locum tenens physician
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0045-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Locum Tenens Physicians
January 2015
Page 34 of 160
on a per diem or similar fee-for-time basis.
Reimbursement to the regular physician or medical group is based on
the applicable fee schedule or contracted/negotiated rate. The locum
tenens physician may not provide services to a member for longer than
60 continuous days. Services included in a global fee payment are not
eligible for separate reimbursement when provided by a locum tenens
physician (i.e., postoperative only services).
A member’s regular physician or medical group should bill the
appropriate procedure code(s) identifying the service(s) provided by
the locum tenens physician with a Modifier Q6 appended to each
procedure code.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies



Modifier usage
Reimbursement of sanctioned and opt-out provider
Scope of practice
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Other Provider Preventable Conditions
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare does not reimburse for other provider preventable conditions
(OPPC) as identified by CMS contracts and/or requirements.
Procedures identified as OPPC will be rejected or denied.
Policy
OPPC is defined and categorized as one of the following:

Surgical or other invasive procedure performed on the wrong body
part

Surgical or other invasive procedure performed on the wrong
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0062-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Other Provider Preventable Conditions
January 2015
Page 36 of 160
patient

Wrong surgical or other invasive procedure performed on a patient
Erroneous surgical events occurring during an inpatient stay should be
reflected on Type of Bill 0110 (nopay claim) along with all services or
procedures related to the surgery. All other inpatient procedures and
services should be submitted in a separate claim.
Note: The PC modifier is defined as “wrong surgery on a patient.” It
should not be used to represent the professional component of a
service. Claims that incorrectly use this modifier may be denied.
Claims with this modifier used incorrectly must be resubmitted as a
corrected claim and indicate the appropriate coding for the service(s)
rendered.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions


Claims requiring additional documentation
Claims submission – Required information for facilities
Claims submission – Required information for professional
provider
Documentation standards for episodes of care
Global surgical package
Present on admission indicator for health-care acquired conditions

None


Related policies


Related materials
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Present on Admission Indicator for Health Care-Acquired Conditions
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare requires the identification of hospital-acquired conditions and
health care-acquired conditions (both referred to as health care
acquired conditions [HCAC]) through the submission of a present on
admission (POA) indicator for all diagnoses on all facility claims
unless otherwise noted by CMS.
In accordance with the Deficit Reduction Act of 2005, POA indicators
(see exhibit A) are required for all inpatient discharges on or after
October 1, 2007. The POA indicator is required for all primary and
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0066-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Present on Admission Indicator for Health-Acquired Conditions
January 2015
Page 38 of 160
secondary diagnosis codes but is not required on the admitting
diagnosis. Failure to include the POA indicator with the primary and
secondary diagnosis codes may result in the claim being denied or
rejected.
If the POA indicator identifies an HCAC, the reimbursement for that
episode of care may be reduced or denied. UniCare will not apply
payment reduction if a condition defined as HCAC for a particular
patient existed prior to the initiation of treatment for that patient by
that provider.
Unless noted in exhibit B, this requirement applies to all facilities.
If an HCAC is caused by one provider or facility (primary), payment
will not be denied to the secondary provider or facility that treated the
HCAC.
UniCare reserves the right to request additional records to support
documentation submitted for reimbursement.
Note: Claims may be subject to clinical review for appropriate
reimbursement consideration.
History

References and
research materials
This policy has been developed through consideration of the
following:
 CMS
 State Medicaid
 State contract
 Code of Federal Regulations (CFR) Subpart A-Payments §447.26
 Federal Register Vol. 76, No. 108- A. The Medicare Program and
Quality Improvements Made in the Deficit Reduction Act of 2005
(DRA) (Pub. L. 109–171) and E. Section 2702 of the Affordable
Care Act
 Federal Register Vol. 76, No. 160- I. Implementation of HospitalAcquired Condition (HAC) Reduction Program for FY 2015
Definitions

General Reimbursement Policy Definitions

Claims requiring additional documentation
Claims submission – Required information for facilities
Claims submission – Required information for professional
providers
Documentation standards for episodes of care
Global surgical package

Related policies



UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Present on Admission Indicator for Health-Acquired Conditions
January 2015
Page 39 of 160
Related materials



Exhibit A: Present on admission indicators and description
Exhibit B: Medicare exempt facilities
Exhibit C: Healthcare-acquired condition categories
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Requirements for Documentation of Proof of Timely Filing
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare will reconsider reimbursement of a claim that is denied for
failure to meet timely filing requirements, unless provider, state, federal
or CMS contracts and/or requirements indicate otherwise, when a
provider can:
Policy

Provide a date of claim receipt compliant with applicable timely
filing requirements

Demonstrate “good cause” exists
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0068-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Requirements for Documentation of Proof of Timely Filing
January 2015
Page 41 of 160
Documentation of claim receipt
The following information will be considered proof that the claim was
received timely. If the claim is submitted:

By United States mail: First class, return receipt requested or by
overnight delivery service - The provider must provide a copy of the
claim log that identifies each claim included in the submission

Electronically: The provider must provide the clearinghouse
assigned receipt date from the reconciliation reports

By fax: The provider must provide proof of facsimile transmission

By hand delivery: The provider must provide a claim log that
identifies each claim included in the delivery and a copy of the
signed receipt acknowledging the hand delivery
The claims log maintained by providers must include the following
information:

Name of claimant

Address of claimant

Telephone number of claimant

Claimant's federal tax ID number

Name of addressee

Name of carrier

Designated address

Date of mailing or hand delivery

Subscriber name

Subscriber ID number

Patient name

Date(s) of service/occurrence, total charge and delivery method
Good cause
Good cause may be established by the following:

If the claim includes an explanation for the delay (or other evidence
which establishes the reason), UniCare will determine good cause
based primarily on that statement or evidence.

If the evidence leads to doubt about the validity of the statement,
UniCare will contact the provider for clarification or additional
information necessary to make a “good cause” determination.
Good cause may be found when a physician or supplier claim filing
delay was due to:
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Requirements for Documentation of Proof of Timely Filing
January 2015
Page 42 of 160

Administrative error – incorrect or incomplete information furnished
by official sources (e.g., carrier, intermediary, CMS) to the
physician or supplier

Incorrect information furnished by the member to the physician or
supplier resulting in erroneous filing with another care management
organization plan or with the state

Unavoidable delay in securing required supporting claim
documentation or evidence from one or more third parties despite
reasonable efforts by the physician/supplier to secure such
documentation or evidence

Unusual, unavoidable or other circumstances beyond the service
provider’s control which demonstrate that the physician or supplier
could not reasonably be expected to have been aware of the need to
file timely

Destruction or other damage of the physician’s or supplier’s records
unless such destruction or other damage was caused by the
physician’s or supplier’s willful act of negligence
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies


Acknowledgement of receipt and received date for EDI submission
Claims timely filing: Participating and nonparticipating
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Reimbursement for Items under Warranty
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow reimbursement for repair or replacement of
rented or purchased items during the warranty period designated by the
applicable manufacturer unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise.
Items include:

Durable medical equipment

Supplies
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0071-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement for Items Under Warranty
January 2015
Page 44 of 160

Prosthetics

Orthotics
The manufacturer and/or distributor is responsible for:

Repairing the item or providing an acceptable replacement item

All fees associated with shipment of the defective item

All fees associated with delivery of the repaired item
In circumstances where UniCare has reimbursed the provider for repair
or replacement of an item during the warranty period, UniCare is
entitled to recoup fees from the manufacturer and/or distributor holding
the warranty. Providers are required to supply members with
information concerning the manufacturer’s warranty for all items
dispensed to members.

UniCare will consider reimbursement for replacement of the item
through another manufacturer, after review, only in circumstances
where both the member and member’s provider deem the
manufacturer’s replacement of the applicable item unacceptable.
The design, materials, measurements, fabrications, testing, fitting
and training in the use of another manufacturer’s replacement item
are included in the reimbursement of the item and are not
separately reimbursable expenses.

If the manufacturer offers an acceptable reduced-price replacement,
but either the member prefers another replacement at full price or a
provider did not utilize the reduced-price offer, UniCare allows
reimbursement only up to the cost of the reduced-price item under
the “prudent buyer” rule.

If the manufacturer offers an acceptable replacement, but imposes a
charge or pro rata payment, UniCare allows reimbursement for the
partial payment imposed by the manufacturer, subject to approval.
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies

None
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Reimbursement of Claims with Charge Discrepancies
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for claims submitted with an itemized
statement where there is a discrepancy in total charges less than $100
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise.
Itemized claims with discrepancies totaling more than $100 or claims
submitted that are not itemized and contain a discrepancy between the
line item and the total amount billed will be denied and returned to the
provider as an unclean claim. The provider will be required to resubmit
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0072-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement of Claims with Charge Discrepancies
January 2015
Page 46 of 160
a corrected claim for reimbursement.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 American Medical Association
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies

Claims timely filing: Participating and nonparticipating
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Reimbursement of Sanctioned and Opt-Out Providers
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow reimbursement to providers who are excluded
or debarred from participation in state and federal health care
programs. UniCare also does not allow reimbursement to providers
who have rendered services to members enrolled in any Medicare
program if such provider has opted out from participation in Medicare.
Services that are rendered by such a provider that is sanctioned or has
opted out of participation in Medicare may only be reimbursed in
urgent or emergent situations. Claims received for services other than
emergency services submitted by sanctioned or opt-out providers as
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0074-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement of Sanctioned and Opt-Out Providers
January 2015
Page 48 of 160
provided herein will be denied.
UniCare will allow reimbursement to a sanctioned or opt-out provider
for emergency items or services only if the claim is accompanied by a
sworn statement of the person furnishing the items or services
specifying:

The nature of the emergency

Why the items or services could not have been furnished by a
provider eligible to furnish or order such items or services
Note: Payment may not be made for services furnished by an opt-out
physician or practitioner who has signed a private contract with a
Medicare beneficiary for emergency or urgent care items.
UniCare screens providers through all applicable state and federal
exclusion lists.
History

References and
research materials
This policy has been developed through consideration of medical
necessity, generally accepted standards of medical practice and review
of medical literature and government approval status, in addition to the
following:
 CMS
 State Medicaid
 State contract
 Code of Federal Regulations
 Social Security Act
Definitions

General Reimbursement Policy Definitions
Related policies


Claims requiring additional documentation
Emergency services: Nonparticipating providers and facilities
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Scope of Practice
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement for services that are within the
provider’s scope of practice under state law in accordance with CMS
guidelines unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise.
Policy
The provider shall be licensed in or hold a license recognized in the
jurisdiction where the patient encounter occurs.
UniCare allows reimbursement for telemedicine performed within the
provider’s scope of practice as regulated by state law.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0076-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Scope of Practice
January 2015
Page 50 of 160
Scope of practice is determined by:

Advanced practice education in a role and specialty

Legal implications

Scope of practice statements as published by national professional
specialty and advanced organizations

State medical licensure requirements

Federal regulations
Services provided outside of a practitioner’s scope of practice are not
covered or reimbursable.
UniCare allows reimbursement for providers with nonresidency but
who have advanced training performing services in a medically
underserved area as allowed by state law.
UniCare allows reimbursement for providers when no board-certified
physicians are available to meet local requirements as allowed by state
law.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 42 CFR §440.2 – Code of Federal Regulations on Scope of Practice
UniCare review approved and effective 03/01/15

Definitions
Related policies
Related materials
Scope of Practice refers to:
o The extent to which providers may render health care services
and the extent they may do so independently
o The type of diseases, ailments, and injuries a health care
provider may address (American Medical Association glossary
of terms).
 General Reimbursement Policy Definitions
 Locum tenens physicians
 Professional anesthesia services
 Reimbursement of sanctioned and opt-out providers

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Site of Service Payment Differential – Professional
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Administration
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare applies site of service payment differential for professional
services based on the setting in which they were provided unless
provider, state, federal or CMS contracts and/or requirements indicate
otherwise. Reimbursement is based on one of the following:
 The applicable fee schedule or contracted/negotiated rate in line
with the state or provider contract, which may include a site of
service differential
 The applicable out-of-network reimbursement rate for
nonparticipating providers
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0077-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Site of Service Payment Differential - Professionals
January 2015
Page 52 of 160
Some services, by nature of their description, are performed only in
certain settings and have only one maximum allowable fee per code.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
UniCare review approved and effective 03/01/15

Definitions
Site of Service Differential: Some professional services may be
provided either in a facility or a non-facility. When a professional
service is provided in a facility, the costs of the clinical personnel,
equipment and supplies are incurred by the facility, not the
physician practice. For this reason, reimbursement for professional
services provided in a facility may be lower than if the services
were performed in a non-facility setting. This difference in
reimbursement, based on where the professional service is
performed, is often referred to as a “site of service differential.”
 Facility Rate: The rate paid for professional services performed in
a facility setting
 Non-facility Rate: The rate paid for professional services
performed in a setting that is not a facility
 General Reimbursement Policy Definitions
Related policies

None
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Professional Anesthesia Services
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Anesthesia
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of policies
into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for anesthesia services rendered by
professional providers for covered members unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on:

The reimbursement formula for the allowance and time increments
in accordance with CMS.

Proper use of applicable modifiers.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0025-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Professional Anesthesia Services
January 2015
Page 54 of 160
Providers must report anesthesia services in minutes. Anesthesia claims
submitted with an indicator other than minutes may be rejected or
denied. Start and stop times must be documented in the member’s
medical record. Anesthesia time starts with the preparation of the
member for administration of anesthesia and stops when the anesthesia
provider is no longer in personal and continuous attendance. The
reimbursement formula for anesthesia allowance is based upon CMS
guidelines, unless otherwise noted in the exemption section.
Anesthesia modifiers
Anesthesia modifiers are appended to the applicable procedure code to
indicate the specific anesthesia service or who performed the service.
Modifiers identifying who performed the anesthesia service must be
billed in the primary modifier field to receive appropriate
reimbursement. Additional or reduced payment for modifiers is based
on state requirements, as applicable. If there is no state requirement,
UniCare will default to the following CMS guidelines. Claims submitted
for anesthesiology services without the appropriate modifier will be
denied.

Modifier AA: Anesthesiology service performed personally by an
anesthesiologist — reimbursement is based on 100% of the
applicable fee schedule or contracted/negotiated rate

Modifier AD: Medical supervision by a physician; more than four
concurrent anesthesia procedures — reimbursement is based on
100% of the applicable fee schedule or contracted/negotiated rate for
up to three base units for anesthesiologists who supervise three or
more concurrent or overlapping procedures

Modifier QK: Medical direction of two, three or four concurrent
anesthesia procedures involving qualified individuals —
reimbursement is based on 50% of the applicable fee schedule or
contracted/negotiated amount

Modifier QX: Certified registered nurse anesthetist (CRNA) service
with medical direction by a physician — reimbursement is based on
50% of the applicable fee schedule or contracted/ negotiated amount

Modifier QY: Anesthesiologist medically directs one CRNA —
reimbursement is based on 50% of the applicable fee schedule or
contracted/negotiated amount

Modifier QZ: CRNA service without medical direction by a
physician — reimbursement is based on 100% of the applicable fee
schedule or contracted/negotiated amount

Modifier 23: Denotes a procedure that must be done under general
anesthesia due to unusual circumstances although normally done
under local or no anesthesia — reimbursement is based on 100% of
the applicable fee schedule or contracted/negotiated rate of the
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Professional Anesthesia Services
January 2015
Page 55 of 160
procedure. Modifier 23 does not increase or decrease
reimbursement; it substantiates billing anesthesia associated with the
procedure in cases where anesthesia is not usually appropriate

Modifier 47: Denotes regional or general anesthesia services
provided by the surgeon performing the medical procedure. UniCare
does not allow reimbursement of anesthesia services by the provider
performing the medical procedure other than obstetrical (see
obstetrical anesthesia section of this policy); therefore, it is not
appropriate to bill Modifier 47.
Multiple anesthesia procedures
UniCare allows reimbursement for professional anesthesia services
during multiple procedures. Reimbursement is based on the anesthesia
procedure with the highest base unit value and the overall time of all
anesthesia procedures.
Obstetrical anesthesia
UniCare allows reimbursement for professional neuraxial epidural
anesthesia services provided in conjunction with labor and delivery for
up to 300 minutes by either the delivering physician or a qualified
provider other than the delivering physician based on the time the
provider is physically present with the member. Providers must submit
additional documentation upon dispute for consideration of
reimbursement of time in excess of 300 minutes. Reimbursement is
based on one of the following:

For the delivering physician — based on a flat rate or fee schedule
using the surgical CPT pain management codes for epidural
analgesia

For a qualified provider other than the delivering physician — based
on:
o The allowance calculation
o The inclusion of catheter insertion and anesthesia
administration
Services provided in conjunction with anesthesia
UniCare allows separate reimbursement for the following services
provided in conjunction with the anesthesia procedure or as a separate
service. Reimbursement is based on the applicable fee schedule or
contracted/negotiated rate with no reporting of time.

Swan-Ganz catheter insertion

Central venous pressure line insertion

Intra-arterial lines

Emergency intubation (must be provided in conjunction with the
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Professional Anesthesia Services
January 2015
Page 56 of 160
anesthesia procedure to be considered for reimbursement)

Critical care visits

Transesophageal echocardiography
Nonreimbursable
UniCare does not reimburse for:

Use of patient status modifiers or qualifying circumstances codes
denoting additional complexity levels

Anesthesia consultations on the same date as surgery or the day prior
to surgery if part of the preoperative assessment

Anesthesia services performed for noncovered procedures, including
services considered not medically necessary, experimental and/or
investigational

Anesthesia services by the provider performing the basic procedure,
except for a delivering physician providing continuous epidural
analgesia

Local anesthesia considered incidental to the surgical procedure

Standby anesthesia services
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Society of Anesthesiologists
 Optum Learning: Understanding Modifiers, 2014 edition

Definitions
Anesthesia: Drugs or substances that cause a loss of consciousness
or sensitivity to pain
 Base unit: Relative value unit associated with each anesthesia
procedure code as assigned by CMS
 Time unit: An increment of 15 minutes where each 15-minute
increment constitutes one time unit
 Conversion factor: A geographic-specific amount that varies by the
locality where the anesthesia is administered
 General Reimbursement Policy Definitions
Related policies


Modifier usage
Scope of practice
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Assistant at Surgery (Modifiers 80/81/82/AS)
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding / Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for one assistant surgeon when eligible
procedures are billed with Modifiers 80, 81, 82 or AS, as applicable
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise. UniCare uses code editing software to process
claims billed for assistant at surgery. If an applicable modifier is not
billed appropriately, the procedure may be denied.
When multiple procedures are performed where only some of the
procedures are eligible for assistant at surgery reimbursement, only
assistant at surgery services for the eligible procedures will be
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0026-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Assistant at Surgery
January 2015
Page 58 of 160
considered for reimbursement. The same multiple-procedure fee
reductions and clinical edits apply to both the assistant at surgery and
the primary surgeon.
The assistant at surgery should not report procedure codes different
from the procedure codes reported by the primary surgeon, except if
the primary surgeon bills a global code (e.g., maternity antepartum,
delivery and postpartum); then the assistant at surgery would bill the
specific surgery code (e.g., delivery only) with the appropriate
modifier.
Assistant surgeon services are eligible for reimbursement as follows:
History
References and
research materials
Definitions




Modifier 80: 16%
Modifier 81: 16%
Modifier 82: 16%
Modifier AS: 14%

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 80: Denotes an assistant at surgery providing full
assistance to the primary surgeon
 Modifier 81: Denotes an assistant at surgery providing minimal
assistance to the primary surgeon
 Modifier 82: Denotes an assistant at surgery when a qualified
resident surgeon is not available to assist the primary surgeon
 Modifier AS: denotes an assistant at surgery who is a nonphysician
(e.g., physician assistant, nurse practitioner)
 General Reimbursement Policy Definitions
Related policies


Code and clinical editing guidelines
Modifier usage
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Diagnoses Used in DRG Computation
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare ensures that the diagnosis and procedure codes that generate
the diagnosis related groups (DRG) are accurate, valid and sequenced
in accordance with national coding standards and specified guidelines
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise.
UniCare performs DRG audits to determine that the diagnostic and
procedural information that led to the DRG assignment is
substantiated by the medical record. The audits utilize coding criteria
to limit the billed diagnosis used in DRG computation to the
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0127-15 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Diagnoses Used in DRG Computations
January 2015
Page 60 of 160
following:

Those that are relevant to the patient’s care

Those that impact the patient’s outcome, treatment, intensity of
service or length of stay

Those that are supported by documentation within the medical
record.
UniCare routinely monitors DRG billing patterns to ensure that
hospitals perform fair and equitable coding and utilization.
History

References and
research materials
This policy has been developed through consideration of the
following:
 CMS
 State Medicaid
 State contract
 American Medical Association

Definitions

UniCare review approved and effective 03/01/15
Diagnosis Related Groups (DRG) are a patient classification
method which provides a means of relating the type of patients a
hospital treats to the costs incurred by the hospital.
General Reimbursement Policy Definitions
Related policies


Documentation standards for an episode of care
Present on admission indicator for health-care acquired
conditions
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
Effective Date: 08/24/15
Committee Approval Obtained: 08/24/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claim submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with Current Procedure Terminology
(CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The
codes denote the services and/or procedures performed. The billed code(s) are required to be fully
supported in the medical record and/or office notes. Unless otherwise noted within the policy, our
policies apply to both participating and nonparticipating providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or Centers for Medicare & Medicaid Services (CMS) contracts and/or requirements. System
logic or setup may prevent the loading of policies into the claims platforms in the same manner
as described; however, UniCare strives to minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for a procedure or service that is
distinct or independent from other service(s) performed on the same
day by the same provider when billed with Modifier 59, XE, XP, XS or
XU unless provider, state, federal, or CMS contracts and/or
requirements indicate otherwise.
Modifier 59 should be used when a more descriptive modifier, like an
XE, XP, XS or XU, collectively referred to as –X{EPSU} is not
available. The –X{EPSU} modifiers are more selective versions of
Modifier 59; it would be incorrect to include both modifiers on the
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0127-15 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
January 2015
Page 62 of 160
same claim line.
Modifier
Description
59
Used to indicate that a procedure or service was
distinct or independent from other services performed
on the same day. Modifier 59 is used to identify
procedures or services that are not normally reported
together, but are appropriate under the circumstances
XE
Separate Encounter, used to indicate a service that is
distinct because it occurred during a separate
encounter
XP
Separate Practitioner, used to indicate a service is
distinct because it was performed by a different
practitioner
XS
Separate Structure, used to indicate a service is distinct
because it was performed on a separate organ/structure
XU
Unusual Non-Overlapping Service, the use of a service
that is distinct because it does not overlap usual
components of the main service
UniCare reserves the right to perform post-payment review of claims
submitted with Modifier 59 and –X{EPSU}. UniCare may request that
providers submit additional documentation, including medical records
or other documentation not directly related to the member, to support
claims submitted by the provider. If documentation is not provided
following the request or notification, or if documentation does not
support the services billed for the episode of care, we may:

Deny the claim

Recover and/or recoup monies previously paid on the claim
UniCare is not liable for interest or penalties when payment is denied
or recouped because the provider fails to submit required or requested
documentation.
Nonreimbursable
UniCare does not allow reimbursement for the above listed modifiers
in the following circumstances:

The modifier is billed with Evaluation & Management (E&M)
codes

The modifier is billed with radiation therapy management codes

A different modifier would describe the situation more accurately
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Distinct Procedural Services (Modifiers 59, XE, XP, XS, XU)
January 2015
Page 63 of 160
NOTE: Refer to individual modifier policies for specific modifier
requirements, guidelines, and exemptions.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Medical Association: Coding with Modifiers, Fifth
Edition
 Optum Learning: Understanding Modifiers, 2015 Edition
 U.S. Department of Health & Human Services, Office of the
Inspector General, Semiannual Report to Congress, 1 October 2005
– 31 March 2006
 U.S. Department of Health & Human Services, Office of the
Inspector General, Use of Modifier 59 to Bypass Medicare’s
National Correct Coding Initiative Edits, OEI-03-02-00771,
November 2005
Definitions

General Reimbursement Policy Definitions





Professional Anesthesia Services
Claims Requiring Additional Documentation
Code and Clinical Editing Guidelines
Maternity Services
Modifier 24: Unrelated Evaluation and Management Service by
Same Physician during Postoperative Period
Modifier 25: Significant, Separately Identifiable Evaluation and
Management Service by Same Physician on Same Day of
Procedure or Other Service
Modifier 57: Decision for Surgery
Modifier 78: Unplanned Return to Operating/Procedure Room by
Same Physician Following Initial Procedure for a Related
Procedure during Postoperative Period
Modifier Usage
Multiple and Bilateral Surgery: Professional and Facility
Reimbursement

Related policies




Related materials

Initial UniCare review approved and effective 08/24/15
None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 22: Increased Procedural Service
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for procedure codes appended with
Modifier 22 when the procedure or service provided is greater than
what is usually required for the listed procedure code unless provider,
state, federal or CMS contracts and/or requirements indicate otherwise.
UniCare performs prepayment review to support the use of Modifier
22. If medical review of the documentation submitted with the claim
supports Modifier 22, reimbursement is based on 120% of the fee
schedule or contracted/negotiated rate for the procedure appended with
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0047-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 22: Increased Procedural Services
January 2015
Page 65 of 160
Modifier 22.
If the documentation does not support the use of Modifier 22 or there is
no documentation submitted with the claim, reimbursement will not
exceed 100% of the fee schedule or contracted/negotiated rate of the
procedure.
Modifier 22 is appropriate to use only with surgery, radiology,
pathology, laboratory and medicine procedure codes with a global
period of 0, 10, or 90 days.
Nonreimbursable
UniCare does not allow reimbursement for use of Modifier 22:

With an inappropriate procedure code

With procedures that do not have a global period (i.e., add-on
codes)

To indicate a procedure performed by a specialist
UniCare does not allow additional reimbursement for anesthesia
services billed with Modifier 22.
History
References and
research materials
Definitions

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Medical Association: Coding with Modifiers, Fifth
Edition
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 22: Indicates that the work required to provide a service
is substantially greater than typically required
 General Reimbursement Policy Definitions
Related policies

Modifier usage
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 24: Unrelated Evaluation and Management Service by the Same
Physician during the Postoperative Period
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows limited reimbursement for physician claims billed with
Modifier 24 unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise.
Policy
Reimbursement is based on 100% of the applicable fee schedule or
contracted/negotiated rate for the evaluation and management (E&M)
service performed during the postoperative period of the original
procedure if the following criteria are met:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0049-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 24: Unrelated Evaluation and Management Service by the Same
Physician during the Postoperative Period
January 2015
Page 67 of 160

The appropriate level of E&M service is billed and appended with
Modifier 24.

A diagnosis code unrelated to the original procedure is indicated for
the E&M service.

The reason for the E&M service is clearly documented in the
member’s medical record.
Failure to use Modifier 24 correctly may result in denial of the E&M
service, and/or claim payments may be recouped and/or recovered.
History
References and
research materials
Definitions

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 24: Used to indicate that the same physician needed to
perform an evaluation and management (E&M) service unrelated to
the original procedure during the postoperative period of the
original service. E&M services performed during the postoperative
period of the original service usually are considered part of the
global surgical package.
 General Reimbursement Policy Definitions
Related policies

Modifier usage
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 25: Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Same Day of the Procedure
or Other Service
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows limited reimbursement for physician claims billed with
Modifier 25 unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise.
Policy
Reimbursement is based on 100% of the applicable fee schedule or
contracted/negotiated rate for the significant, separately identifiable
evaluation and management (E&M) service performed by the same
provider on the same day of the original service or procedure if the
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0048-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 25: Significant, Separately Identifiable Evaluation and Management
Service by the Same Physician on the Same Day of the Procedure or Other Service
January 2015
Page 69 of 160
following criteria are met:

The appropriate level of E&M service is billed.

Modifier 25 is appended to the E&M service, which is above and
beyond the other service or procedure provided (including usual
preoperative and postoperative care associated with the procedure).

The reason for the E&M service is clearly documented in the
member’s medical record.

The documentation supports that the member’s condition required
the significantly separate E&M service.
Failure to use Modifier 25 correctly may result in denial of the E&M
service. UniCare reserves the right to perform postpayment review of
claims submitted with Modifier 25.
History
References and
research materials
Definitions

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 25: Used to indicate that on the day a procedure or
service was performed, the member’s condition required a
significant, separately identifiable E&M service above and beyond
the original service, or above and beyond the usual preoperative
and postoperative care associated with the original procedure. The
E&M service may be prompted by the symptom or condition for
which the procedure and/or service was performed, so separate
diagnoses codes are not required to report E&M codes on the same
date. E&M services are not separately reimbursed from surgical
and procedural services since these require appropriate provider
involvement.
 General Reimbursement Policy Definitions
Related policies



Modifier 57: Decision for surgery
Modifier usage
Preventive medicine and sick visits on the same day
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 57: Decision for Surgery
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows separate reimbursement for an evaluation and
management (E&M) visit provided on the day prior to or the day of a
major surgery, when billed with Modifier 57 to indicate the E&M visit
resulted in the initial decision to perform the major surgical procedure
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise. A major surgery has a 90-day global period.
Reimbursement for the E&M visit is based on 100% of the applicable
fee schedule or contracted/negotiated rate. UniCare reserves the right to
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0050-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 57: Decision for Surgery
January 2015
Page 71 of 160
request medical records for review to support payment for the E&M
visit. Failure to use this modifier when appropriate may result in denial
of the claim for the visit.
Nonreimbursable
UniCare does not allow reimbursement for services billed with
Modifier 57 in the following circumstances unless state, federal or
CMS contracts and/or requirements indicate otherwise:

An E&M visit the day before or day of the surgery (e.g.,
preoperative evaluation) when the decision to perform the surgery
was made prior to the E&M visit

An E&M visit for minor surgeries (0- or 10-day global period);
since the decision to perform a minor surgery is usually reached the
same day or day before the procedure, is considered a routine
preoperative service

A service with non-E&M codes
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Medical Association: Coding with Modifiers, Fifth
Edition
 Optum Learning: Understanding Modifiers, 2014 edition
Definitions

General Reimbursement Policy Definitions



Global surgical package
Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier usage

None
Related policies
Related materials
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 59: Distinct Procedural Service
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for a procedure or service that is
distinct or independent from other service(s) performed on the same
day by the same provider when billed with Modifier 59 unless
provider, state, federal or CMS contracts and/or requirements indicate
otherwise.
UniCare reserves the right to perform postpayment review of claims
submitted with Modifier 59. UniCare may request additional
documentation or notify the provider of additional documentation
required for claims, subject to contractual obligations. If documentation
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0051-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 59: Distinct Procedural Service
January 2015
Page 73 of 160
is not provided following the request or notification, UniCare may
recoup or recover monies previously paid on the claim, as the provider
failed to submit required documentation for postpayment review.
Nonreimbursable
UniCare does not allow reimbursement for Modifier 59 when:

Billed with evaluation & management (E&M) codes

Billed with radiation therapy management codes

A different modifier would describe the situation more accurately
Note: Refer to individual modifier policies for specific modifier
requirements and guidelines.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Medical Association: Coding with Modifiers, Fifth
Edition
 Optum Learning: Understanding Modifiers, 2014 Edition
 U.S. Department of Health & Human Services, Office of the
Inspector General, Semiannual Report to Congress, 1 October 2005
– 31 March 2006
 U.S. Department of Health & Human Services, Office of the
Inspector General, Use of Modifier 59 to Bypass Medicare’s
National Correct Coding Initiative Edits, OEI-03-02-00771,
November 2005

Definitions

UniCare review approved and effective 03/01/15
Modifier 59: Used to indicate that a procedure or service was
distinct or independent from other services performed on the same
day. Modifier 59 is used to identify procedures or services that are
not normally reported together, but are appropriate under the
circumstances. This may represent any of the following:
o A different session
o A different procedure or surgery
o A different site or organ system
o A separate incision or excision
o A separate lesion
o A separate injury (or area of injury in extensive injuries) not
ordinarily encountered or performed on the same day by the
same individual
General Reimbursement Policy Definitions
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 59: Distinct Procedural Service
January 2015
Page 74 of 160





Related policies




Related materials

Claims requiring additional documentation
Code and clinical editing guidelines
Maternity services
Modifier 24: Unrelated evaluation and management service by
same physician during postoperative period
Modifier 25: Significant, separately identifiable evaluation and
management service by same physician on same day of procedure
or other service
Modifier 57: Decision for surgery
Modifier 78: Unplanned return to operating/procedure room by
same physician following initial procedure for a related procedure
during postoperative period
Modifier usage
Multiple and bilateral surgery: Professional and facility
reimbursement
None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 62: Co-Surgeons
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of procedures eligible for co-surgeons
when billed with Modifier 62 unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise.
Policy
Reimbursement to each surgeon is based on 62.5% of the applicable
fee schedule or contracted/negotiated rate. Co-surgeons may be from
the same specialty, or they may be from different specialties operating
on separate body systems. Co-surgery is always performed during the
same operative session.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0052-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 62: Co-Surgeons
January 2015
Page 76 of 160
Each surgeon must bill the same procedure code(s) with Modifier 62. If
one or both surgeons fail to use the modifier appropriately, it is
possible that one surgeon may receive 100% of the applicable fee
schedule or negotiated/contracted rate, and the other surgeon’s claim
may be denied or pended due to a duplicate or suspected duplicate
service, respectively.
Assistant surgeon and/or multiple procedures rules and fee reductions
apply if:
History
References and
research materials
Definitions

A co-surgeon acts as an assistant in performing additional
procedure(s) during the same surgical session.

Multiple procedures are performed.

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 62: Used to indicate two surgeons, usually from different
specialties, where the participation of both surgeons is necessary in
performing a specific operative procedure. Two surgeons may be
necessary due to the complex nature of the procedure(s) or the
member’s condition.
 General Reimbursement Policy Definitions

Related policies
Related materials

Assistant at surgery (Modifiers 80/81/82/AS)
Duplicate or subsequent services on the same date of service
Modifier usage
Multiple and bilateral surgery reimbursement

None


UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 63: Procedure Performed on Infants less than 4 kg
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows additional reimbursement for surgery on neonates and
infants up to a present body weight of 4 kg when billed with Modifier 63,
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise.
Reimbursement is based on 120% of the applicable fee schedule (not to
exceed the billed charges) or contracted/negotiated rate for the procedure
code when the modifier is valid for services performed. Medical records
may be requested for review to support the additional payment. The
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0053-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 63: Procedures Performed on Infants Less than 4 kg
January 2015
Page 78 of 160
neonate weight should be documented clearly in the report for the
service.
When an assistant surgeon is used and/or multiple procedures are
performed on neonates or infants less than 4 kg in the same operative
session, assistant surgeon and/or multiple procedure rules and fee
reductions apply.
Nonreimbursable
UniCare does not allow reimbursement for Modifier 63 billed in the
following circumstances:
History
References and
research materials
Definitions
Related policies

For facility billing

With evaluation and management codes

With anesthesia codes

With radiology codes

With pathology/laboratory codes

With medicine codes

With Modifier 63-exempt codes

In addition to Modifier 22 (unusual services) for the same procedure
code(s)

With codes denoting invasive procedures that include “neonate” or
“infant” in the description (e.g., surgery to correct a congenital
abnormality), since the reimbursement rate for the code already
reflects the additional work

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 The Essential RBRVS, 2014 edition
 Modifier 63: Used to indicate a surgical procedure was performed on
a neonate or infant up to a present body weight of 4 kg. The modifier
is intended to capture procedures performed on neonates and infants
within a certain weight limit, as these procedures may involve
significantly increased complexity and physician work.
 General Reimbursement Policy Definitions


Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 63: Procedures Performed on Infants Less than 4 kg
January 2015
Page 79 of 160
Related materials

Multiple and bilateral surgery

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 66: Surgical Teams
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of procedures eligible for surgical
teams when billed with Modifier 66 unless provider, state, federal or
CMS contracts and/or requirements indicate otherwise.
Policy
UniCare performs a prepayment review to support the use of Modifier
66. Providers must submit documentation with claims billed with
Modifier 66. Claims submitted without documentation will be denied.
Each physician participating in the surgical team must bill the
applicable procedure code(s) for their individual services with Modifier
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0054-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 66: Surgical Teams
January 2015
Page 81 of 160
66. If any or all physicians participating in the surgery fail to use the
modifier appropriately, claims may be denied or pended for duplicate
or suspected duplicate services, respectively.
Multiple procedure rules and fee reductions apply if the surgical team
performs multiple procedures unless surgeons of different specialties
are each performing a different procedure. Assistant surgery rules and
fee reductions apply if any member of the surgical team acts as an
assistant performing additional procedure(s) during the same surgical
session.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition

Definitions




None


Related materials
Modifier 66: Used in circumstances where highly complex
procedures or the nature of the member’s condition require the
services of a surgical team.
A surgical team consists of:
o More than two physicians from different specialties performing
different procedures (identified by different procedure codes)
o Other highly skilled, specially trained personnel
o Various types of complex equipment
The surgical team concept is performed during the same operative
session. Surgical teams may be appropriate for procedures
including, but not limited to, organ transplants, surgeries on
multiple organ systems, amputation, coronary artery bypass,
surgery of the skull base to remove tumors or certain vertebral body
resections.
General Reimbursement Policy Definitions
Assistant at surgery (Modifiers 80/81/82/AS)
Claims requiring additional documentation
Duplicate or subsequent services on the same date of service
Modifier usage
Multiple and bilateral surgery reimbursement

Related policies
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 76: Repeat Procedure by the Same Physician
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement for applicable procedure codes
appended with Modifier 76 to indicate a procedure or service was
repeated by the same physician:
Policy

Subsequent to the original procedure or service for professional
provider claims.

On the same date as the original procedure or service for facility
claims.
Unless provider, state, federal or CMS contracts and/or requirements
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0055-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 76: Repeat Procedure by Same Physician
January 2015
Page 83 of 160
indicate otherwise, reimbursement is based on the following use of
Modifier 76:

For a nonsurgical procedure or service: 100% of the applicable fee
schedule or contracted/negotiated rate

For a surgical procedure: 100% of the applicable fee schedule or
contracted/negotiated rate for the surgical component only limited
to a total of two surgical procedures
Professional services, other than radiology which is excluded from this
requirement, will be subject to clinical review for consideration of
reimbursement. Providers must submit supporting documentation for
the use of Modifier 76 with the claim. If a claim is submitted with
Modifier 76 without supporting documentation, the claim will be
denied. Providers will be asked to submit the required documentation
for reconsideration of reimbursement. Failure to use Modifier 76 when
appropriate may result in denial of the procedure or service.
If a repeated surgical procedure is performed with an assistant surgeon
or in conjunction with multiple surgeries, assistant surgeon and/or
multiple procedure rules and fee reductions apply.
Nonreimbursable
UniCare does not allow reimbursement for use of Modifier 76:
History
References and
research materials
Definitions
Related policies

With an inappropriate procedure code(e.g., laboratory/pathology)

For a surgical procedure repeated more than once

For the preoperative or postoperative components of a surgical
procedure

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Code editing guidelines
 Optum Learning: Understanding Modifiers, 2014 edition
 Subsequent: The time period after the initial procedure or service
is performed and within the global period designated for that
procedure or service.
 General Reimbursement Policy Definitions



Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
Multiple and bilateral surgery reimbursement
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 76: Repeat Procedure by Same Physician
January 2015
Page 84 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 77: Repeat Procedure by Another Physician
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement for applicable procedure codes
appended with Modifier 77 to indicate a procedure or service was
repeated by another physician:
Policy

Subsequent to the original procedure or service for professional
claims.

On the same date as the original procedure or service for facility
claims.
Unless provider, state, federal or CMS contracts and/or requirements
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0056-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 77: Repeat Procedure by Another Physician
January 2015
Page 86 of 160
indicate otherwise, reimbursement is based on the following use of
Modifier 77:

For a nonsurgical procedure or service: 100% of the applicable fee
schedule or contracted/negotiated rate

For a surgical procedure: 100% of the applicable fee schedule or
contracted/negotiated rate for the surgical component only limited
to a total of two surgical procedures
Professional services, other than radiology which are excluded from
this requirement, will be subject to clinical review for consideration of
reimbursement. Providers must submit supporting documentation for
the use of Modifier 77 with the claim. If a claim is submitted with
Modifier 77 without supporting documentation, the claim will be
denied. Providers will be asked to submit the required documentation
for reconsideration of reimbursement. Failure to use Modifier 77 when
appropriate may result in denial of the procedure or service.
If a repeated surgical procedure is performed with an assistant surgeon
or in conjunction with multiple surgeries, assistant surgeon and/or
multiple procedure rules and fee reductions apply.
Nonreimbursable
UniCare does not allow reimbursement for use of Modifier 77:
History
References and
research materials
Definitions
Related policies

With an inappropriate procedure code (e.g., laboratory/pathology)

For a surgical procedure repeated more than once

For the preoperative or postoperative components of a surgical
procedure

When appended to evaluation and management codes

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Subsequent: The time period after the initial procedure or service
is performed and within the global period designated for that
procedure or service.
 General Reimbursement Policy Definitions



Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
Multiple and bilateral surgery reimbursement
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 77: Repeat Procedure by Another Physician
January 2015
Page 87 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 78: Unplanned Return to the Operating/Procedure Room by the
Same Physician Following Initial Procedure for a Related Procedure during the
Postoperative Period
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for claims billed with Modifier 78 unless
provider, state, federal or CMS contracts and/or requirements indicate
otherwise, when the following criteria are met:

The return to the operating or procedure room is unplanned

The procedure appended with Modifier 78 is:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0057-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 78: Unplanned Return to the Operating/Procedure Room
January 2015
Page 89 of 160
o The appropriate surgical code for the procedure performed.
o Performed by the same physician who provided the initial
procedure.
o Related to the initial procedure.
o Performed during the postoperative period of the initial procedure.
Reimbursement is based on 100% of the fee schedule or contracted/
negotiated rate of the surgical procedure code when the modifier is valid
for the service performed. Reimbursement is based on the surgical
procedure only, not including preoperative or postoperative care.
Procedures rendered during the postoperative period and not billed with
Modifier 78 are normally denied as included in the global surgical
package.
When an assistant surgeon is used and/or multiple procedures are
performed during the global period in the same operative session,
assistant surgeon and/or multiple procedure rules and fee reductions
apply.
Nonreimbursable
UniCare does not allow reimbursement for Modifier 78 billed in the
following circumstances including, but not limited to:

With non-surgical codes

With codes denoting “subsequent,” “related” or “redo” in the
description
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 The Essential RBRVS, 2014 edition

Definitions

Related policies



Modifier 78: Used to indicate that a subsequent procedure was
performed during the postoperative period of the original surgical
procedure. The subsequent procedure must be related to the original
procedure and must require a return trip to the operating or procedure
room.
General Reimbursement Policy Definitions
Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
Multiple and bilateral surgery: Professional and facility
reimbursement
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 78: Unplanned Return to the Operating/Procedure Room
January 2015
Page 90 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier 91: Repeat Clinical Diagnostic Laboratory Test
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of claims for repeat clinical diagnostic
laboratory tests appended with Modifier 91 unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Policy
Reimbursement is based on 100% of the applicable fee schedule or
contracted/negotiated rate of the clinical diagnostic laboratory test
billed with Modifier 91.
Medical documentation may be requested to support the use of
Modifier 91. Failure to use the modifier appropriately may result in
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0058-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier 91: Repeat Clinical Diagnostic Laboratory Test
January 2015
Page 92 of 160
denial of the repeated laboratory test as a duplicate service.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 Edition
 The Essential RBRVS, 2014 Edition
UniCare review approved and effective 03/01/15

Definitions
Modifier 91: Used to indicate a clinical diagnostic laboratory test
was repeated on the same day for the same member to obtain
multiple test results. Modifier 91 may not be used in the following
situations:
o To repeat a test to confirm initial results, or because there was a
problem with the specimen or equipment when performing the
initial test
o When other code(s) describe a series of test results
 General Reimbursement Policy Definitions
Related policies

Modifier usage
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifiers LT and RT: Left Side/Right Side Procedures
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for procedure codes appended with
Modifier LT and/or RT when indicating the side of the body for which
the item, supply or procedure will be used unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on 100% of the fee schedule or contracted/
negotiated rate of the procedure. Modifiers LT and RT are
informational modifiers and therefore do not increase or decrease
reimbursement of the procedure.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0059-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier LT and RT: Left Side/Right Side Procedures
January 2015
Page 94 of 160
It is inappropriate to use Modifier LT or Modifier RT when billing for
bilateral procedures, or with procedure codes containing “bilateral” or
“unilateral or bilateral” in their description. Modifiers LT and RT do
not indicate a bilateral service. Claims submitted with Modifiers LT
and RT appropriately indicating a surgical procedure was performed on
both the left side and right side of the body are subject to multiple
surgery rules.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
Definitions

General Reimbursement Policy Definitions
Related policies


Modifier usage
Multiple and bilateral surgery reimbursement
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Modifier Usage
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for covered services provided to
eligible members when billed with appropriate procedure codes and
appropriate modifiers when applicable unless provider, state, federal or
CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on the code-set combinations submitted with
the correct modifiers. The use of certain modifiers requires the provider
to submit supporting documentation along with the claim. Refer to the
specific modifier policies (exhibit A) for guidance on documentation
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0060-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier Usage
January 2015
Page 96 of 160
submission.
Applicable electronic or paper claims billed without the correct
modifier in the correct format may be rejected or denied. The modifier
must be in capital letters, if alpha or alphanumeric. Rejected or denied
claims must be resubmitted with the correct modifier in conjunction
with the code-set to be considered for reimbursement. Corrected and
resubmitted claims are subject to timely filing guidelines. The use of
correct modifiers does not guarantee reimbursement.
Reimbursement modifiers
Reimbursement modifiers affect payment and denote circumstances
when an increase or reduction is appropriate for the service provided.
The modifiers must be billed in the primary or first modifier field
locator.
Informational modifiers impacting reimbursement
Informational modifiers determine if the service provided will be
reimbursed or denied. Modifiers that impact reimbursement should be
billed in modifier locator fields after reimbursement modifiers, if any.
Informational modifiers not impacting reimbursement
Informational modifiers are used for documentation purposes.
Modifiers that do not impact reimbursement should be billed in the
subsequent modifier field locators. UniCare reserves the right to
reorder modifiers to reimburse correctly for services provided. In the
absence of state-specific modifier guidance, UniCare will default to
CMS guidelines.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 The Essential RBRVS, 2014 edition
Definitions

General Reimbursement Policy Definitions
Related policies







Assistant at surgery (80/81/82/AS)
Claims timely filing
Consultations
Duplicate services on the same date of service
Early and periodic screening, diagnostic and treatment
Modifier 22: Increased procedural service
Modifier 24: Unrelated evaluation and management service by
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Modifier Usage
January 2015
Page 97 of 160













same physician during postoperative period
Modifier 25: Significant, separately identifiable evaluation and
management service by same physician on same day of procedure
or other service
Modifier 57: Decision for surgery
Modifier 59: Distinct procedural service
Modifier 62: Co-surgeons
Modifier 63: Procedure on infants less than 4kg
Modifier 66: Surgical teams
Modifier 76: Repeat procedure by same physician
Modifier 77: Repeat procedure by another physician
Modifier 78: Unplanned return to operating/ procedure room by
same physician following initial procedure for a related procedure
during postoperative period
Modifier 91: Repeat laboratory test
Modifier LT and RT left side-right side procedures
Multiple bilateral surgery professional and facility reimbursement
Physician standby services
Portable-mobile-handheld radiology
Preadmission services
Preventive medicine and sick visits on the same day
Professional anesthesia services
Reduced or discontinued services (52/53/73/74)
Robotic assisted surgery
Split-care modifiers (54/55/56)
Transportation services
Vaccines for children

Exhibit A: Reimbursement modifiers listing









Related materials
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Multiple and Bilateral Surgery: Professional and Facility Reimbursement
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement to professional providers and facilities
for multiple and bilateral surgery unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise. Reimbursement is
based on Medicaid-based multiple fee reductions in accordance with
applicable contracts or state guidelines for applicable surgical procedures
performed at the same session by the same provider.
Multiple surgery
Professional provider claims for applicable surgical procedures must be
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0061-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Multiple and Bilateral Surgery: Professional and Facility Reimbursement
January 2015
Page 99 of 160
billed with Modifier 51 to denote a multiple surgery. Facility claims
should not be billed with Modifier 51. However, the following fee
reductions apply to both physician and facility claims. Medicaid-based
reimbursement is the total of:

100% of the fee schedule or contracted/negotiated rate for the
primary (i.e., highest valued) procedure

50% for the secondary procedure

50% for 3rd through 5th procedures, with the 6th and additional
procedures only if determined to be medically necessary through
clinical review
UniCare does not apply multiple fee reduction reimbursement to
“Modifier 51 - exempt” (also known as “MS-exempt”) or “add-on”
procedure codes since the fee allowance and/or relative value is already
reduced for the procedure itself.
Bilateral surgery
Professional provider and facility claims with applicable surgical
procedures must be billed with Modifier 50 to denote a bilateral surgery.
It is inappropriate to use Modifier LT or RT to identify bilateral
procedures. Medicaid-based reimbursement is 150% of the fee schedule
or contracted/negotiated rate of the procedure.
For procedure codes containing “bilateral” or “unilateral” in their
description, no modifier is used and reimbursement is based on 100% of
the fee schedule or contracted/negotiated rate for the procedure.
In the instance when more than one bilateral procedure or multiple and
bilateral procedures are performed during the same operative session, the
multiple fee reductions apply.
Claims with applicable surgical procedures billed without the correct
modifier to denote either multiple or bilateral surgery may be denied.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 National uniform billing committee guidelines
 Optum Learning: Understanding Modifiers, 2014 edition
Definitions

General Reimbursement Policy Definitions
Related policies


Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Multiple and Bilateral Surgery: Professional and Facility Reimbursement
January 2015
Page 100 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Reimbursement for Reduced and Discontinued Services
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement to professional providers and facilities
(i.e., outpatient hospital/ambulatory surgery center) for reduced or
discontinued services when appended with the appropriate modifier
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise.

Append Modifier 52 to indicate
o Procedures for which services performed are significantly less
than usually required.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0070-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement for Reduced and Discontinued Services
January 2015
Page 102 of 160
o Reimbursement is reduced to 50% of the applicable fee
schedule or contracted/negotiated rate.
o Do not report on evaluation and management (E&M) and
consultation codes.

Append Modifier 53 to indicate
o The physician elects to terminate a surgical or diagnostic
procedure due to extenuating circumstances that threaten the
well-being of the patient.
o Reimbursement is reduced to 50% of the applicable fee
schedule or contracted/negotiated rate.
o Modifier 53 is not applicable for facility billing.
o Modifier 53 is not valid when billed with E&M code or timebased codes.

Append Modifier 73 to indicate
o The physician canceled the surgical or diagnostic procedure
prior to administration of anesthesia and/or surgical preparation
of the patient.
o Reimbursement is reduced to 50% of the applicable fee
schedule or contracted/negotiated rate.
o Modifier 73 is not applicable for professional provider billing.

Append Modifier 74 to indicate
o A procedure was stopped after the administration of anesthesia
or after the procedure was started (i.e., incision made, intubation
started, scope inserted).
o Reimbursement is 100% of the applicable fee schedule or
contracted/negotiated rate.
o Modifier 74 is not applicable for professional provider billing.
If the reduced or discontinued procedure is performed with an assistant
surgeon or in conjunction with multiple surgeries, assistant surgeon
and/or multiple procedure rules and fee reductions apply. We reserve
the right to perform postpayment review of claims submitted with
Modifiers 52, 53, 73 and 74.
History

References and
research materials
This policy has been developed through consideration of medical
necessity, generally accepted standards of medical practice, and review
of medical literature and government approval status, in addition to the
following:
 CMS
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement for Reduced and Discontinued Services
January 2015
Page 103 of 160



State Medicaid
State contract
Optum Learning: Understanding Modifiers, 2014 edition
Definitions

General Reimbursement Policy Definitions
Related policies



Assistant at surgery (Modifiers 80/81/82/AS)
Modifier usage
Multiple and bilateral surgery reimbursement
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Reimbursement of Services with Obsolete Codes
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow reimbursement for services billed with
obsolete codes, in compliance with industry standard coding practices
according to the Health Insurance Portability and Accountability Act of
1996 (HIPAA). Billing with obsolete codes is not HIPAA-compliant.
Claims submitted for services using obsolete codes will be denied.
Providers must resubmit claims with applicable new or replacement
codes to have services considered for reimbursement. Resubmitted
claims are subject to claims timely filing guidelines.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0102-15 June 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Reimbursement of Services with Obsolete Codes
June 2015
Page 105 of 160
History

References and
Research Materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Federal Register Vol. 65, No. 160 45 CFR Parts 160 and 162
Health Insurance Reform: Standards for Electronic Transactions
 National Correct Coding Initiative
 HIPAA Compliance Guidelines
Definitions

General Reimbursement Policy Definitions
Related Policies


Claims Timely Filing: Participating and Nonparticipating
Code and clinical editing guidelines
Related Materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Robotic Assisted Surgery
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow separate or additional reimbursement for the
use of robotic surgical systems unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise. Surgical techniques
requiring use of robotic surgical systems will be considered integral to
surgical services and not a separate service. Reimbursement will be
based on the payment for the standard surgical procedure(s).
Providers should not append surgery codes with Modifier 22, increased
procedural service, to indicate robotic assisted surgery in order to
receive separate or additional reimbursement for use of robotic surgical
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0075-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Robotic Assisted Surgery
January 2015
Page 107 of 160
systems. Claims billed with Modifier 22 solely for the purpose of
reporting robotic assisted surgery will be denied or subject to
recoupment. Modifier 22 should only be used to report unusual
complications or complexities which occurred during the surgical
procedure that are unrelated to the use of a robotic assistance system
and must be supported by documentation.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 U.S. Food and Drug Administration (FDA)
Definitions

General Reimbursement Policy Definitions
Related policies

Modifier 22: Increased procedural service
Related materials

None
UniCare review approved and effective 03/01/15
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Split-Care Surgical Modifiers
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our Reimbursement Policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of surgical codes appended with “splitcare modifiers,” unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise.
Policy
Reimbursement is based on a percentage of the fee schedule or
contracted/negotiated rate for the surgical procedure. The percentage is
determined by which modifier is appended to the procedure code:

Modifier 54 (surgical care only): 70%
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0078-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Split-Care Surgical Modifiers
January 2015
Page 109 of 160

Modifier 55 (postoperative management only): 20%

Modifier 56 (preoperative management only): 10%
The global surgical package consists of preoperative services, surgical
procedures, and postoperative services. Total reimbursement for a
global surgical package is the same regardless of how the billing is split
between the different physicians involved in the member’s care. When
more than one physician performs services that are included in the
global surgical package, the total amount reimbursed for all physicians
may not be higher than what would have been paid if a single physician
provided all services.
Correct coding guidelines require that the same surgical procedure
code (with the appropriate modifier) be used by each physician to
identify the services provided when the components of a global
surgical package are performed by different physicians.
Claims received with split-care modifiers after a global surgical claim
has been paid will be denied.
When an assistant surgeon is used and/or multiple procedures are
performed, assistant surgeon and/or multiple procedure rules and fee
reductions apply.
History
References and
research materials
Definitions
Related policies

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition
 Modifier 54: Used to indicate that a surgeon performed only the
surgical component of a global surgical package (i.e., another
physician provides postoperative care)
 Modifier 55: Used to indicate that a physician other than the
surgeon performed only the postoperative management component
of a global surgical package
 Modifier 56: Used to indicate that a physician other than the
surgeon performed only the preoperative evaluation component of a
global surgical package
 General Reimbursement Policy Definitions




Assistant at surgery (Modifiers 80/81/82/AS)
Clinical code editing guidelines
Modifier usage
Multiple and bilateral surgery reimbursement
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Split-Care Surgical Modifiers
January 2015
Page 110 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Unlisted or Miscellaneous Codes (aka: Dump Codes)
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Coding
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for unlisted or miscellaneous codes
(aka dump codes) in accordance with specified guidelines unless
provider, state, federal or CMS contracts and/or requirements indicate
otherwise. Unlisted or miscellaneous codes should only be used when
an established code does not exist to describe the service, procedure, or
item rendered.
Reimbursement is based on review of the unlisted or miscellaneous
code(s) on an individual claim basis. Claims submitted with unlisted or
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0081-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Unlisted or Miscellaneous Codes
January 2015
Page 112 of 160
miscellaneous codes must contain the following information and/or
documentation for consideration during review:

A written description, office notes or operative report describing
the procedure or service performed

An invoice and written description of items and supplies

The corresponding national drug code number for an unlisted drug
code
History

UniCare review approved and effective 03/01/15
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract


Unlisted or Miscellaneous Codes are used for service(s) or
item(s):
o Not having a designated code fitting the description of the
service(s) or item(s) rendered (aka “catch-all” code)
o To circumvent:
 Code edit software logic, such as:
 Duplicate claim
 Incident to
 Mutually exclusive
 Unbundling logic
 Benefit limitations and exclusions (e.g., noncovered
services)
 Fee allowances (i.e., maximize reimbursement)
Unlisted or miscellaneous codes may be used for a variety of
services or items. As new and advanced approaches and
techniques are under development, the unlisted category is used
for auditing purposes until these procedures become accepted in
medical practice and are routinely performed by providers.
Specific fee allowances and/or relative value units cannot be
established for unlisted services or items.
General Reimbursement Policy Definitions
Related policies

None
Related materials

None
Definitions
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Drugs and Injectable Limits
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Drugs
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for drug claims received with
HCPCS/CPT procedure codes that do not contain medically unlikely
edit (MUE) limits and are within the physical quantities of drugs (also
known as units) unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise.
Drug claims must be submitted as required with applicable HCPCS or
CPT procedure code(s), national drug codes, appropriate qualifier, unit
of measure, number of units and price per unit. Units should be
reported in the multiples included in the code descriptor used for the
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0035-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Drug and Injectable Limits
January 2015
Page 114 of 160
applicable HCPCS codes.
Reimbursement will be considered up to the clinical unit limits (CUL)
allowed for the prescribed/administered drug. UniCare utilizes the
CMS MUE value. When there is no MUE assigned by CMS, identified
codes will have a CUL assigned or calculated based on the prescribing
information, the Food and Drug Administration and established
reference compendia.
Claims that exceed the CUL will be reviewed for documentation to
support the additional units. If the documentation does not support the
additional units billed, the additional units will be denied.
History
References and
research materials
Definitions

This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Food and Drug Administration
 The appropriateness of the specific treatment for which a drug is
being prescribed is recognized and supported in one of the
following established reference compendia:
a) American hospital formulary service-drug information
b) National comprehensive cancer network drugs and biologics
compendium
c) Thomson Micromedex DrugDex®
d) Elsevier/Gold Standard clinical pharmacology
 General Reimbursement Policy Definitions


Claims submission- Required information for professional
providers
Unlisted and miscellaneous codes

None
Related policies
Related materials
UniCare review approved and effective TBD
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Facility Take-Home Drugs
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Drugs
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc.(UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow reimbursement of take-home drugs – those
dispensed by a facility for take-home use – under the inpatient or
outpatient hospital benefit unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise.
Claims submitted by a facility for drugs with revenue codes denoting
take-home use will be denied.
History

UniCare review approved and effective 03/01/15
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0040-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Facility Take-Home Drugs
January 2015
Page 116 of 160
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions


Take-Home Use: Intended for use outside of a facility
General Reimbursement Policy Definitions
Related policies

None
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Consultations
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: E&M/Medicine
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for face-to-face medical consultations
by physicians or qualified nonphysician practitioners (referred to as
“provider(s)”) in accordance with specified guidelines unless provider,
state, federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on the fee schedule or contracted/negotiated
rate structured on one of the following:

The appropriate code designating a consultation based on state
Medicaid guidelines (i.e., for codes containing “consultation” in
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0032-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Consultations
January 2015
Page 118 of 160
their description)

The appropriate code designating a consultation based on CMS
guidelines
Consultations
Consultations are reimbursable according to the following guidelines:

The consultation is requested in writing or verbally by the attending
provider or appropriate source

The consultation is provided within the scope and practice of the
consulting provider

The consultation includes a personal examination of the patient

The consulting provider completes a written report that includes:
o Member history, including chief diagnosis and/or complaint
o Examination
o Physical finding(s)
o Recommendations for future management and/or ordered
service(s)

The member’s medical record must contain:
o
The attending provider’s request for the consultation
o
The reason for the consultation
o Documentation that indicates the information communicated by
the consulting provider to the member’s attending provider and
the member’s authorized representative
The consulting provider’s written report
o

Laboratory consultations must relate to test results that are outside
the clinically significant normal or expected range considering the
member’s condition

During a consultation, the consulting provider may initiate
diagnostic and/or therapeutic services
o If the consulting provider performs a definitive therapeutic
surgical procedure on the same day as the consultation for the
same member, the consultation must be reported with Modifier
25 or Modifier 57, whichever is most appropriate.

If the appropriate modifier is not reported, the consultation
is considered included in the reimbursement for the
therapeutic surgical procedure; therefore, not separately
reimbursable.
Preoperative clearance and postoperative evaluation
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Consultations
January 2015
Page 119 of 160
A surgeon may request a provider perform a consultation as part of
either a preoperative clearance or postoperative evaluation, as long as
consultation guidelines are met in addition to the following:

A consulting provider may be reimbursed for a postoperative
evaluation only if:
o The requesting surgeon requires a professional opinion for use
in treating the member.
o The consulting provider has not performed the preoperative
clearance.

Postoperative visits are considered concurrent care and do not
qualify for reimbursement as consultations if:
o A consulting provider performs a preoperative clearance.
o Subsequent management of all or a portion of the member’s
postoperative care is transferred to the same consulting provider
who performed the preoperative clearance.
Note: The following do not qualify as consultations:

Routine screenings

Routine preoperative or postoperative management care including,
but not limited to:
o Member history and physical for the surgical procedure being
performed
o Services applicable to be billed with the surgical procedure code
appended with Modifier 56
o Services applicable to be billed with the surgical procedure code
appended with Modifier 55
Consultation by a primary care physician
A primary care physician (PCP) may perform a consultation for his/her
own patient in the following circumstances:

A surgeon has specifically requested the PCP to perform either a
preoperative clearance or a postoperative evaluation, as long as:
o Consultation, preoperative clearance and/or postoperative
evaluation guidelines are met
o Preoperative and/or postoperative consultations rendered by the
member’s PCP are reimbursable services based on state
guidance or the provider’s contract
The preoperative visit usually is included in the surgeon’s global
surgical allowance. Medical review may be required if the PCP is
reimbursed for a service normally included in the global fee allowance
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Consultations
January 2015
Page 120 of 160
(i.e., duplicate service).

A behavioral health provider has specifically requested the PCP to
perform a consultation to provide either a medical evaluation for a
specific condition or a general medical evaluation (i.e., history and
physical) on a member admitted to an inpatient psychiatric unit for
behavioral health treatment. These occurrences usually are billed as
evaluation and management (E&M) visits. Medical review may be
required to ensure consultation guidelines are met.
Note: A PCP is responsible for the care of his/her own patient and,
therefore, does not usually qualify to perform consultations because:

Such services are considered “evaluations” rather than
“consultations.”

The PCP has an established medical record and/or history on the
member.
Consultation within the same group practice
A consultation may be considered for reimbursement if the attending
provider requests a consultation from another provider of a different
specialty or subspecialty within the same group practice, as long as
consultation guidelines are met.
Nonreimbursable
UniCare does not allow reimbursement for the following with regard to
a consultation:

Performed by telephone (telephone calls are not considered
telemedicine)

Performed as a split or shared E&M visit

Performed in addition to an E&M visit for the same member by the
same provider, unless Modifier 25 is appropriate

Performed as a second or third opinion requested by the member or
member’s authorized representative

Performed for noncovered services

When a transfer of care to the consulting provider occurs (i.e.,
subsequent visits for the same patient by the same consulting
provider)

For both preoperative clearance and postoperative evaluation of the
same member by the same consulting provider

When provided by a surgeon immediately prior to the procedure
and resulted in the initial decision to perform surgery

For which the specified guidelines are not met
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Consultations
January 2015
Page 121 of 160
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American Medical Association
UniCare review approved and effective 03/01/15

Definitions
Consultation: A deliberation by two or more providers with
respect to the diagnosis, prognosis and/or treatment in any
particular case where the expertise, professional opinion and
medical judgment of the consulting provider are considered
necessary.
 Second Opinion: An opinion obtained from an additional health
care professional prior to the performance of a medical service or a
surgical procedure. May relate to a formalized process, either
voluntary or mandatory, which is used to help educate a patient
regarding treatment alternatives and/or to determine medical
necessity.
 General Reimbursement Policy Definitions

Related policies



Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier 57: Decision for surgery
Modifier usage
Split care surgical modifiers
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Physician Standby Services
Effective Date: 03/01/15
Committee Approval Obtained: 03/19/15
Section: E&M
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow separate reimbursement for physician standby
services unless provider, state, federal or CMS contracts and/or
requirements indicate otherwise. Reimbursement for physician standby
services is included in the applicable facility rate. Professional or
facility claims submitted for separate reimbursement for physician
standby services will be denied.
Providers should not append Modifier 59, distinct procedural service,
to indicate physician standby services in order to receive separate or
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0101-15 June 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Physician Standby Services
June 2015
Page 123 of 160
additional reimbursement. Claims billed with Modifier 59 to indicate
physician standby services will be denied or subject to recovery or
recoupment.
If, during the standby period, the standby physician performs services,
therefore rendering direct care to the member, the standby physician
may be separately reimbursed only for the professional services,
subject to service coverage. The standby service will not be separately
reimbursed.
Services for attendance and initial stabilization of a newborn at a
vaginal or cesarean delivery, at the request of the delivering physician
when there is documented fetal distress or reasonable anticipation of
newborn distress, are not considered physician standby services.
Note: Attendance and initial stabilization services are represented by a
different procedure code than physician stabilization services.
Attendance and initial stabilization of a newborn involves the physician
rendering direct care to the newborn, and therefore may be a separately
reimbursable expense from the facility rate.

History

References and
Research Materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract

Definitions

Related Policies
Related Materials
Biennial Anthem review approved 03/19/15: History, related
policies, and policy template updated
Initial UniCare review approved and effective 03/01/15

Physician Standby Services: Represents occasions where the
physician is present and available for a prolonged period, at the
request of the primary physician, in case the standby physician’s
specific expertise and skills become necessary in the treatment of a
member. The physician is not rendering direct care to the
respective, or any other, member during standby.
General Reimbursement Policy Definitions

Maternity Services
Modifier 59: Distinct procedural service

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Preventive Medicine and Sick Visits on the Same Day
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: E&M
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for preventive medicine (i.e., well-child
visits) and limited sick visits on the same day, unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on the fee schedule or contracted/negotiated
rate for the preventive medicine and the allowed sick visit under the
following conditions:

Modifier 25 must be billed with the applicable evaluation and
management code for the allowed sick visit—if Modifier 25 is not
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0067-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Preventive Medicine and Sick Visits on the Same Day
January 2015
Page 125 of 160
billed appropriately, the sick visit will be denied.

Appropriate diagnosis codes must be billed for respective visits.
Federally qualified health centers and rural health centers reimbursed
other than through UniCare’s fee schedule or state encounter rates are
not subject to this policy.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions

Code and clinical editing guidelines
Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Related policies
Related materials


UniCare review approved and effective 03/01/15
None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Preadmission Services for Inpatient Stays
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Facilities
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for applicable services for a covered
member prior to admission to an inpatient hospital (referred to as the
payment window) unless provider, state, federal or CMS contracts
and/or requirements indicate otherwise, based on CMS guidance as
follows:

For admitting hospitals, applicable preadmission services are
included in the inpatient reimbursement for the three days prior to
and including the day of the member’s admission, and therefore,
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0065-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Preadmission Services for Inpatient Stays
January 2015
Page 127 of 160
are not separately reimbursable expenses
Note: This includes any entity wholly owned or wholly operated by the
admitting hospital or by another entity under arrangements with the
admitting hospital (i.e., the admitting hospital owns the physician’s
practice performing the preadmission services).

For other hospitals and units, applicable preadmission services are
included in the inpatient reimbursement within one day prior to and
including the day of the member’s admission and, therefore, are not
separately reimbursable expenses, including:
o
Psychiatric hospitals and units
o
Inpatient rehabilitation facilities and units
o
Long-term care hospitals
o
Children’s hospitals
o
Cancer hospitals

For critical access hospitals, outpatient diagnostic services are not
subject to either the three-day or one-day payment window and,
therefore, are separately reimbursable expenses from the inpatient
stay reimbursement.

The three-day or one-day payment window does not apply to
outpatient diagnostic services included in the rural health clinic or
federally qualified health center all-inclusive rate.
Preadmission services
Applicable preadmission services consist of all diagnostic outpatient
services (including nonpatient laboratory tests) and clinically related
nondiagnostic (i.e., therapeutic) services that are related to the inpatient
stay and are included in the inpatient reimbursement.
A hospital may attest to specific nondiagnostic services as being
unrelated by adding a condition code 51 to the outpatient nondiagnostic
service to be billed separately.
Providers should append Modifier PD to diagnostic and nondiagnostic
services that are subject to the preadmission payment window.
Nonreimbursable
UniCare does not consider the following services to be included in the
payment window prior to an inpatient stay for preadmission services:

Ambulance services

Maintenance renal dialysis services

Services provided by:
o
Skilled nursing facilities
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Preadmission Services for Inpatient Stays
January 2015
Page 128 of 160

o
Home health agencies
o
Hospices
Unrelated diagnostic and nondiagnostic services (i.e., not directly
related to the inpatient stay)
Note: These services may be considered for separate outpatient
reimbursement.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 U.S. Department of Health and Human Services, Office of the
Inspector General Final Report, Expansion of the Diagnosis
Related Group Payment Window, A-01-02-00503, August 2003

Definitions


Related policies
Related materials

UniCare review approved and effective 03/01/15
Condition Code 51: Denotes attestation of Unrelated Outpatient
Non-Diagnostic Services
Modifier PD: Indicates that the service is related to the inpatient
admission
General Reimbursement Policy Definitions

Modifier usage
Transportation services

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Early and Periodic Screening, Diagnostic and Treatment
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Prevention
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member’s benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of early and periodic screening,
diagnostic and treatment (EPSDT) program services unless provider,
state, federal or CMS contracts and/or requirements indicate otherwise.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0038-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Early and Periodic Screening, Diagnostic and Treatment
January 2015
Page 130 of 160
Reimbursement is based on the applicable fee schedule or
contracted/negotiated rate.
The following EPSDT component services are included in the
reimbursement of the preventive medicine evaluation and management
(E&M) visit, unless appended with Modifier 25, to indicate a
significant, separately identifiable E&M service by the same physician
on the same date of service:

Comprehensive health history

Comprehensive unclothed physical examination

Health education

Nutritional assessment

Hearing screening with or without the use of an audiometer or other
electronic device

Dental screening

Vision screening
The following component services are separately reimbursable from
the preventive medicine E&M visit:

Developmental screening using a standardized screening tool

Immunization and administration

Laboratory tests:
o Newborn metabolic screening test
o Tuberculosis test
o Hematocrit and hemoglobin tests
o Lead toxicity screening
o Cholesterol test
o Pap smear, for sexually active members
o Sexually transmitted disease screening, for sexually active
members
o Urinalysis
Providers should follow periodicity guidelines established by the
American Academy of Pediatrics and the Centers for Disease Control
and Prevention. If a provider performs EPSDT services in conjunction
with a sick visit, all services are subject to UniCare’s preventive
medicine and sick visits on same day policy.
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Early and Periodic Screening, Diagnostic and Treatment
January 2015
Page 131 of 160
Claims requirements
Provider claims for EPSDT services should include all of the following
items:
History
References and
research materials
Definitions

EPSDT special program indicator

EPSDT referral indicator codes (aka referral condition codes), if
applicable

Appropriate diagnosis code(s)

Appropriate HCPCS code identifying the completed EPSDT
service (list in addition to code for appropriate E&M service)

Appropriate E&M codes for new or established members

Appropriate procedure code for the component services

Modifier EP (only with developmental screening/testing)

UniCare review approved and effective 03/01/15
This policy has been developed through consideration of medical
necessity, generally accepted standards of medical practice and review
of medical literature and government approval status, in addition to the
following:





CMS
State Medicaid
State contract
American Academy of Pediatrics
Centers for Disease Control and Prevention

General Reimbursement Policy Definitions

Related policies



Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier usage
Preventive medicine and sick visits on the same day
Vaccines for children program
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Vaccines for Children Program
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Prevention
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for vaccinations provided by the vaccines
for children (VFC) program for eligible members under the age of 19,
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise. Medicaid providers who immunize children shall
participate in the VFC program and comply with all of the reporting
requirements and procedures for provider participants.
Reimbursement is based on the fee schedule or contracted/negotiated rate
of the vaccine administration up to maximum fee limits set by the Centers
for Disease Control and Prevention (CDC) and Modifier SL. UniCare does
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0082-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Vaccines for Children
January 2015
Page 133 of 160
not reimburse providers for the vaccine serum as it is provided free-ofcharge through the VFC program.
Although providers shall only be reimbursed for the administration of the
vaccine, serum code(s) must be included on the claim to meet regulatory
and HEDIS® reporting requirements that members are receiving the proper
immunization(s). Claims submitted without applicable serum,
administration and modifier codes may be rejected and/or denied.
Reimbursement of office visits
Vaccine administrations are separately reimbursable expenses from wellchild exams or office visits. When the vaccine administration is the only
service performed, UniCare does not allow reimbursement for a minimal
office visit (i.e., an office or other outpatient visit for the evaluation and
management of an established patient that may not require the presence of
a physician where the presenting problem(s) are usually minimal and
typically five minutes are spent performing or supervising these services).
Non-VFC members/vaccines
For members not eligible or for vaccines not provided under the VFC
program, UniCare reimburses providers for the administration and serum
based on the fee schedule or contracted/negotiated rate.
Reimbursement during state supply shortages
During documented supply shortages within applicable state VFC
programs, UniCare will reimburse providers for serum(s) based on the fee
schedule or contracted/negotiated rate and applicable modifier. The health
plan shall develop internal processes and procedures to track state VFC
program and CDC information to monitor vaccine shortages.
HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA).
History

References and
research
materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Centers for Disease Control and Prevention
 Social Security Act, Section 1928: Program for Distribution of
Pediatric Vaccines
 State VFC Program
Definitions

General Reimbursement Policy Definitions
Related policies

Modifier usage
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Vaccines for Children
January 2015
Page 134 of 160
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Prosthetic and Orthotic Devices
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Prosthetics and
Orthotics
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of prosthetic and orthotic devices when
provided as part of a physician’s services or ordered by a physician and
used in accepted medical practice unless provider, state, federal or CMS
contracts and/or requirements indicate otherwise.
Reimbursement is based on the applicable fee schedule or
contracted/negotiated rate for the prosthetic or orthotic device dispensed.
The design, materials, measurements, fabrications, testing, fitting and
training in the use of the device are included in the reimbursement of the
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0069-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Prosthetic and Orthotic Devices
January 2015
Page 136 of 160
device and are not separately reimbursable expenses.
Reimbursement is allowed for repair of prosthetic and orthotic devices:

When necessary to make the device serviceable.

When the device is no longer covered under the supplier’s or
manufacturer’s warranty.

Up to the estimated expense of replacement of the device.
Reimbursement is allowed for replacement of prosthetic and orthotic
devices due to:

Change in the patient’s condition.

Substantial change in patient’s growth and/or weight.

Permanent and/or accidental damage.

Irreparable wear in consideration of the reasonable useful lifetime of
the device of not less than five years based on when the equipment is
delivered to the member.
Nonreimbursable
UniCare does not allow reimbursement for prosthetics and orthotics under
the following conditions:

Provision of a device that exceeds the benefit limit unless authorized
through medical necessity

Enhancements or upgrades of a device (i.e., deluxe or luxury) for the
convenience of the member or caregiver

The aesthetic appearance of a device for the preference of the member
or caregiver

A device considered experimental or investigational

Repair or replacement of a device as a result of abuse or neglect

Repair or replacement of a device during the warranty period

Over-the-counter orthotic devices (e.g., items available without a
prescription and not custom fitted for the member)

Dental prosthetics are considered for reimbursement through
delegated agreements between UniCare and contracted dental vendors
In instances of theft, a police report is required for consideration of
replacements.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Prosthetic and Orthotic Devices
January 2015
Page 137 of 160

State contract


Prosthetic Device: An artificial structural and functional replacement
of:
o A limb/appendage or internal organ
o All or part of the function of a permanently inoperative or
malfunctioning internal body organ
Orthotic Device: A brace with rigid metal or plastic stays applied to
the body:
o For support or immobilization of a body part
o To correct or prevent deformity
o To assist or restore function
General Reimbursement Policy Definitions
Related policies

Reimbursement of items under warranty
Related materials

None
Definitions

UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Portable/Mobile/Handheld Radiology Services
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Radiology
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement for portable/mobile radiology services
when furnished in a residence used as the patient’s home if ordered by
a physician and performed by qualified portable radiology suppliers
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise.
Portable/mobile radiology studies should not be performed for routine
purposes or for reasons of convenience. Reimbursement is based on
the applicable fee schedule or contracted/negotiated rate for the
radiological service, and transportation and set-up components with
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0064-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Portable/Mobile/Handheld Radiology Services
January 2015
Page 139 of 160
the use of applicable modifiers.
Note: Portable radiology suppliers must be licensed or registered to
perform services as required by applicable state laws.
Transportation and setup
UniCare allows reimbursement for transportation and setup of
portable radiology equipment when transported to the member’s
residence. Transportation costs are payable when the portable X-ray
equipment used was actually transported to the location where the Xray was taken. Reimbursement for the set-up cost of portable
radiology equipment is not separately reimbursable.
Reimbursement for transportation is based on a single payment for
each particular location regardless of the number of members
receiving radiological services. For services provided to more than
one member, the transportation cost is divided by the total number of
members receiving services at that location. If more than one member
receives portable radiology services, providers must bill with one of
the following applicable modifiers:

Modifier UN – two members served

Modifier UP – three members served

Modifier UQ – four members served

Modifier UR – five members served

Modifier US – six or more members served
o Total payment for the service is divided by six regardless of
the number of members served.

No modifier is required when only one member is served
Nonreimbursable
UniCare does not allow reimbursement for transportation costs of
equipment stored for use as needed at any location qualifying as a
member’s residence.
If the diagnostic X-rays are not covered, payment will not be made for
the transportation and set-up fee.
Handheld radiology
The use of handheld radiology instruments is allowed. Reimbursement
will be part of the physician’s professional service, and no additional
charge will be paid. The technical components for handheld radiology
are not separately reimbursable.
History

References and
This policy has been developed through consideration of the
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Portable/Mobile/Handheld Radiology Services
January 2015
Page 140 of 160
research materials
following:
 CMS
 State Medicaid
 State contract
Definitions

General Reimbursement Policy Definitions
Related policies

Modifier usage
Related materials

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Abortion (Termination of Pregnancy)
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claims submissions. Services should be billed with CPT codes, HCPCS codes
and/or revenue codes. The codes denote the services and/or procedures performed. The billed
code(s) are required to be fully supported in the medical record and/or office notes. Unless
otherwise noted within the policy, our policies apply to both participating and nonparticipating
providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:


Reject or deny the claim
Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement of induced abortions unless provider,
state, federal or CMS contracts and/or requirements indicate otherwise.
Policy
Induced abortions are allowed only when the voluntary and informed
consent has been obtained of the woman upon whom the abortion is to
be performed and the provider performing the procedure certifies:

The pregnancy is the result of an act of rape or incest.

The woman suffers from a physical disorder, injury or illness,
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0023-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Abortion
January 2015
Page 142 of 160
including a life-endangering physical condition caused by or arising
from the pregnancy itself that would, as certified by a physician,
place the woman in danger of death unless an abortion is performed.
Consent form does not have to be submitted for claim payment;
however, it is required to be in the patient’s chart.
Reimbursement is based on the applicable fee schedule or
contracted/negotiated rate when the state-approved certification of
medical necessity abortion form is properly executed.
An informed consent is not needed for the treatment of incomplete,
missed or septic abortions. These procedures are not considered induced
or elective abortions and are allowed under the criteria of medical
necessity.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Code of Federal Regulations (CFR) Subpart E- Abortions §441.200§441.208

UniCare review approved and effective 03/01/15


Abortion, Induced: One resulting from measures taken to
intentionally end a pregnancy, using medications (medical abortion)
or instrumentation (surgery)
Abortion, Incomplete: Part of the product of conception has been
retained in the uterus
Abortion, Missed: A dead, nonviable fetus and other products of
conception are retained in the uterus for two or more months
Abortion, Septic: There is an infection of the product of conception
and the endometrial lining of the uterus usually resulting from
attempted interference during early pregnancy
Abortion Spontaneous/Miscarriage: Occurs when a natural cause
ends a pregnancy prior to 20 weeks
Abortion, Threatened: The appearance of signs and symptoms of
possible loss of embryo
Stillborn: Occurs when a natural cause ends a pregnancy after 20
weeks
Termination of Pregnancy: Synonym for abortion
General Reimbursement Policy Definitions
Related policies

None
Related materials

None



Definitions



UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Global Surgical Package for Professional Providers
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement for the global surgical package unless
provider, state, federal or CMS contracts and/or requirements indicate
otherwise.
Policy
UniCare follows CMS global surgery values. The global surgery package
may be furnished in any setting and reimbursement applies to both major
and minor surgical procedures as defined by their postoperative periods of
90, 10 or 0 days.
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0041-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Global Surgical Package for Professional Providers
January 2015
Page 144 of 160
Included in the global surgical package
Reimbursement for the following components is included within the
global surgical package:

Preoperative services rendered after the decision is made to operate,
beginning with the day before major procedures and the day of
surgery for minor procedures

Intraoperative services that are normally a usual and necessary part of
a surgical procedure

Treatment for all additional medical or surgical services required of
the surgeon during the postoperative period of the surgery because of
complications which do not require additional trips to the operating
room and that are not categorized as a hospital-acquired condition or
present on admission

Postsurgical pain management by the surgeon

Visits during the postoperative periods that are related to recovery
from the surgery

Miscellaneous surgical services and supplies used during the surgery
Unlisted surgical procedures included in global package
Reimbursement for an unlisted surgical procedure is based on the review
of the unlisted code on an individual claim basis. Claims submitted with
unlisted codes must contain any of the following information and/or
documentation describing the procedure or service performed for
consideration during review:

A written description

Office notes

An operative report
Add-on surgical procedures included in global surgical package
The global surgical period for an add-on surgical procedure will be based
on the primary surgical code.
Separately reimbursable from global surgical package
The following services are not included in the payment amount for the
global surgery. The services listed below are separately reimbursable
expenses:

The initial consultation or evaluation by the surgeon to determine the
need for a major surgical procedure

Visits during the postoperative period of surgery that are unrelated to
the diagnosis of the surgery, unless the visits occur due to
complications of the surgery
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Global Surgical Package for Professional Providers
January 2015
Page 145 of 160

Treatment for an underlying condition or an added course of treatment
which is not part of the normal recovery from surgery

Diagnostic tests and procedures

Clearly distinct surgical procedures during the postoperative period
that are not re-operations or treatment for complications

Treatment for postoperative complications which require a return trip
to the operating room

If a less extensive procedure fails, and a more extensive procedure is
required, the second procedure is payable separately

Immunosuppressive therapy for an organ transplant

Critical care services unrelated to the surgery where a seriously
injured or burned member is critically ill and requires constant
attendance of the physician
Providers must use applicable HIPAA-compliant modifiers for any
services provided during the post-operative period. These modifiers are
appended to the corresponding CPT/HCPCS code in conjunction with an
appropriate diagnosis code for reimbursement consideration.
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Code Editing Guidelines
Definitions

General Reimbursement Policy Definitions



Claims requiring additional documentation
Duplicate or subsequent services on the same date of service
Modifier 24: Unrelated evaluation and management service by the
same physician during the postoperative period
Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier 57: Decision for surgery
Modifier 78: Unplanned return to the operating/procedure room by the
same physician following initial procedure for a related procedure
during the postoperative period
Modifier usage
Other provider preventable conditions
Split-care surgical modifiers

Related policies





UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Global Surgical Package for Professional Providers
January 2015
Page 146 of 160
Related materials

Unlisted and miscellaneous codes (aka dump codes)

None
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Hysterectomy
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of nonelective and medically necessary
hysterectomy procedures for covered members unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on the applicable fee schedule or
contracted/negotiated rate and completion of a valid
consent/acknowledgement of hysterectomy form.
UniCare considers reimbursement for a hysterectomy only when the
following criteria are met:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0042-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Hysterectomy
January 2015
Page 148 of 160

The hysterectomy is medically necessary to treat an illness or
injury.

The member has given informed consent.

The member or authorized representative is fully aware that the
hysterectomy will render the member permanently incapable of
reproducing, and has orally and in writing expressed this
understanding.

The member or authorized representative has signed and dated an
applicable state-approved consent/acknowledgement of
hysterectomy form. The form is required regardless of the
member’s diagnosis or age.
Note: The consent/acknowledgement of hysterectomy form with the
physician’s certification is required if the individual was already sterile
before the hysterectomy or if the individual required a hysterectomy
because of a life threatening emergency situation in which the
physician determined that prior consent/acknowledgement was not
possible. The member’s informed consent/acknowledgement of
hysterectomy is not required.
A “valid” consent/acknowledgement of hysterectomy form has to be
properly executed and include all required signatures:

Member, except as noted

Person obtaining the member’s consent

The physician performing the hysterectomy
Consent form does not have to be submitted for claims processing, but
it is required to be in the member’s medical record.
If a hysterectomy is performed in conjunction with a delivery, then
multiple surgery guidelines apply (refer to the UniCare multiple and
bilateral surgery policy).
Nonreimbursable
UniCare does not allow reimbursement of a hysterectomy in the
following circumstances:
History

The hysterectomy is performed for the sole purpose of rendering
the member permanently incapable of reproduction.

There is more than one reason for the hysterectomy, but the
primary reason is to render the member permanently incapable of
reproduction.

The hysterectomy is performed for the purpose of cancer
prophylaxis.

UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Hysterectomy
January 2015
Page 149 of 160
References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American College of Obstetricians and Gynecologists (ACOG)
 Code of Federal Regulations (CFR) Subpart F- Sterilizations
§441.250- §441.258
Definitions

General Reimbursement Policy Definitions

Multiple and bilateral surgery: Professional and facility
reimbursement

Hysterectomy acknowledgment form and acknowledgment of
receipt of hysterectomy information
Instructions for completing the hysterectomy acknowledgment
form
Related policies
Related materials

UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Maternity Services
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare does not allow reimbursement for global obstetrical codes
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise. Antepartum care, deliveries and postpartum care
are reimbursed as individual services.
Providers should use the appropriate evaluation and management
codes for antepartum and postpartum care.
History

UniCare review approved and effective 03/01/15
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0046-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Maternity Services
January 2015
Page 151 of 160
References and
research materials
This policy has been developed through consideration of the
following:
 CMS
 State Medicaid
 State contract
 Current procedural terminology 2014
Definitions

General Reimbursement Policy Definitions





Claims requiring additional documentation
Modifier 25: Significant, separately identifiable evaluation and
management service by the same physician on the same day of the
procedure or other service
Modifier 59: Distinct procedural service
Multiple delivery services
Prenatal ultrasound medical policy

None
Related policies
Related materials
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Sterilization
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Surgery
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
Policy
UniCare allows reimbursement of sterilization procedures performed for the
purpose of rendering a member permanently incapable of reproducing,
unless provider, state, federal or CMS contracts and/or requirements
indicate otherwise. Reimbursement is based on the applicable fee schedule
or contracted/negotiated rate and completion of a state-approved consent
form properly executed per state requirements.
UniCare considers reimbursement of sterilization procedures based on the
following guidelines:
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0079-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Sterilization
January 2015
Page 153 of 160

The member has given informed consent by voluntarily signing the
applicable consent form:
o Not less than 30 and not more than 180 calendar days prior to the
procedure (if more than 180 calendar days prior to the procedure a
new consent form will be required)
o In the case of premature delivery or emergency abdominal surgery,
not less than 72 hours prior to the procedure
At the time the voluntary informed consent is obtained, the member must
be:

At least 21 years of age

Legally and mentally competent

Not institutionalized (e.g., mental hospital or correctional facility)
Consent for sterilization cannot be obtained while the patient to be sterilized
is:

In labor or childbirth

Is under the influence of alcohol or other agents affecting awareness

Seeking to obtain or obtaining an abortion
A “valid” consent form has to be properly executed and include all required
signatures:

Member or member’s authorized representative

Interpreter, if applicable

Person obtaining the member's consent

Physician performing the sterilization procedure
Consent form does not have to be submitted for claims processing, but it is
required to be in the member’s chart.
If a sterilization procedure is performed in conjunction with a delivery, then
multiple surgery guidelines apply (refer to UniCare’s multiple and bilateral
surgery policy).
History

References and
research
materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 American College of Obstetricians and Gynecologists
 Code of Federal Regulations Subpart F- Sterilizations §441.250§441.258
UniCare review approved and effective 03/01/15
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Sterilization
January 2015
Page 154 of 160


Sterilization is the process of making a person permanently unable to
reproduce.
General Reimbursement Policy Definitions
Related policies

Multiple and bilateral surgery reimbursement
Related
materials

None
Definitions
UniCare Health Plan of West Virginia, Inc.
Medicaid Managed Care
Reimbursement Policy
Subject: Transportation Services: Ambulance and Nonemergent Transport
Effective Date: 03/01/15
Committee Approval Obtained: 03/01/15
Section: Transportation
***** The most current version of our reimbursement policies can be found on our provider
website. If you are using a printed version of this policy, please verify the information by going
to www.unicare.com. *****
These policies serve as a guide to assist you in accurate claims submissions and to outline the
basis for reimbursement by UniCare Health Plan of West Virginia, Inc. (UniCare), if the service
is covered by a member’s UniCare benefit plan. The determination that a service, procedure,
item, etc., is covered under a member's benefit plan is not a determination that you will be
reimbursed. Services must meet authorization and medical necessity guidelines appropriate to
the procedure and diagnosis, as well as to the member’s state of residence. You must follow
proper billing and submission guidelines. You are required to use industry-standard, compliant
codes on all claim submissions. Services should be billed with CPT codes, HCPCS codes and/or
revenue codes. The codes denote the services and/or procedures performed. The billed code(s)
are required to be fully supported in the medical record and/or office notes. Unless otherwise
noted within the policy, our policies apply to both participating and nonparticipating providers
and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed,
UniCare may:

Reject or deny the claim

Recover and/or recoup claim payment
UniCare reimbursement policies are developed based on nationally accepted industry standards
and coding principles. These policies may be superseded by mandates in provider, state, federal
or CMS contracts and/or requirements. System logic or setup may prevent the loading of
policies into the claims platforms in the same manner as described; however, UniCare strives to
minimize these variations.
UniCare reserves the right to review and revise our policies periodically when necessary. When
there is an update, we will publish the most current policy to this site.
UniCare allows reimbursement for transport to and from covered
services or other services mandated by contract, unless provider, state,
federal or CMS contracts and/or requirements indicate otherwise.
Reimbursement is based on the guidelines in this policy.
Policy
Due to the complex nature of transportation services, we recommend
that providers also review state guidelines for coverage requirements.
Nonemergent transport services
Nonemergency medical transport (NEMT) entails the transport of a
www.unicare.com
UniCare Health Plan of West Virginia, Inc.
WEB-UWV-0080-14 January 2015
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport
January 2015
Page 156 of 160
member by nonmedically skilled personnel (laypersons) to receive
covered services. There are several types of medical transports:
ambulette/medi-van, wheelchair van, invalid coach, taxicab, mini-bus
and public transportation (e.g., bus and/or subway).
Reimbursement for medical transport services is based on receipt of a
claim or an invoice from contracted transportation vendors or other
suppliers detailing:

The nonemergency medical transport base rate per trip, where a trip
is defined by the origin and destination modifiers

Mileage

Parking and/or toll fees
Ambulance services
Reimbursement for ambulance services is based on:

The ambulance base rate per trip in accordance with the medically
necessary level of care provided to the member, where a trip is
defined by the origin and destination modifiers.

The fee schedule or contracted/negotiated rate for services and
items separately reimbursable from the ambulance base rate.

If ambulance transport is medically necessary for inpatient-toinpatient transfer between hospital-based facilities, reimbursement
is included in the inpatient stay.
Included in the ambulance base rate
Services reimbursed as part of the ambulance base rate:

Ambulance equipment and supplies:
o Disposable/first aid supplies
o Reusable devices/equipment
o Oxygen
o Intravenous drugs

Ambulance personnel services
Separately reimbursable from the ambulance base rate
Services that are not part of the ambulance base rate are separately
reimbursable expenses:

Mileage

Additional appropriately licensed medical personnel as medically
necessary for member’s health status

Unusual waiting time (i.e., in excess of 30 minutes)

Disposable/first aid supplies in greater than normal use
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport
January 2015
Page 157 of 160
Transportation modifiers
Claims for transportation services must be billed with the following
origin and destination modifiers. Claims for transportation services
submitted without origin and destination modifiers will be denied.

Modifier D: Diagnostic or therapeutic site/free standing facility
other than P or H

Modifier E: Residential, domiciliary, custodial facility (e.g.,
nursing home, not a skilled nursing facility)

Modifier G: Hospital-based dialysis facility (hospital or hospitalassociated)

Modifier H: Hospital (inpatient or outpatient)

Modifier I: Site of transfer (e.g., airport or helicopter pad) between
types of ambulance

Modifier J: Nonhospital-based dialysis

Modifier N: Skilled nursing facility, including swingbed

Modifier P: Physician’s office, including HMO nonhospital
facility, clinic, etc.

Modifier R: Private residence

Modifier S: Scene of accident or acute event

Modifier X: Intermediate stop at the physician’s office en route to
hospital (includes HMO nonhospital facility, clinic, etc.)
o Modifier X can only be used as a destination code in the second
position of a modifier.
In addition to the origin and destination modifiers, the following
modifiers are to be used when appropriate:

Modifier GM: Indicates multiple members on one trip

Modifier QL: Indicates the member died after the ambulance was
called

Modifier QM: Indicates the provider arranged for the
transportation services

Modifier QN: Indicates the provider furnished the transportation
services

Modifier TK: Indicates multiple carry trips

Modifier TQ: Indicates life support transport by a volunteer
ambulance provider

Modifiers for transportation of portable/mobile radiology
equipment
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport
January 2015
Page 158 of 160
Nonreimbursable
UniCare does not allow reimbursement of the following for any
ambulance or medical transport service provided:

A member who is not available (i.e., no-show)

Additional rates for night, weekend and/or holiday calls

Mileage in transit to pick up or drop off the member (i.e., unloaded
mileage)

Mileage for additional passengers

Mileage for extra attendant for additional passengers

Mileage when the transport service has been denied or is not
covered

Transport for a member’s or caregiver’s convenience

Transport available free of charge

For ambulance services only:
o For reasons other than medical care
o Where another means of transportation (e.g., medi-van, public
transportation) could be used without endangering the
member’s health
o For separate reimbursement for services/items included in the
base ambulance rate
o For a higher level of care when a lower level is more
appropriate (e.g., advanced life support [ALS] service when
basic life support [BLS] is appropriate)
o For both basic and advanced life support when ALS services are
provided
o For services provided by the emergency medical technician
(EMT) in addition to ALS or BLS base rates
o For services provided on the ambulance by hospital staff
o Additional ground and/or air ambulance providers that respond
but do not transport the member
o Transport from the member’s home to a facility other than a
hospital, skilled nursing facility, dialysis facility or nursing
home
o Transport from a facility other than a hospital, skilled nursing
facility, dialysis facility or nursing home to the member’s home
o Transport of persons other than the member and a medically
required attendant who do not require medical attention
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport
January 2015
Page 159 of 160
o Transport for a member pronounced dead prior to the ground
and/or air ambulance being contacted
o Mileage beyond the nearest appropriate facility (i.e., excessive
mileage)

For medical transport services only:
o Transportation vendor/supplier lodging or meals
o Vehicle maintenance or gas
History

References and
research materials
This policy has been developed through consideration of the following:
 CMS
 State Medicaid
 State contract
 Optum Learning: Understanding Modifiers, 2014 edition

Definitions

UniCare review approved and effective 03/01/15
Ambulance Services
Ambulance services entail the medically necessary transport of a
member by medically skilled personnel to the nearest appropriate
facility equipped to provide care for the member’s injury and/or
illness. Services are initially delineated as basic life support (BLS)
or advanced life support (ALS) levels of care, and then further
delineated as emergency or nonemergency:
o BLS consists of noninvasive services provided by personnel
trained as emergency medical technicians (EMTs) (basic) in
conjunction with applicable state laws.
o ALS consists of invasive services provided by personnel trained
as EMTs (intermediate or paramedic) in conjunction with
applicable state laws.
o Emergency ambulance transportation is an urgent service in
which the member experiences a sudden, unexpected onset of
acute illness or injury requiring immediate medical or surgical
care which the member secures immediately after the onset, (or
as soon thereafter as practical) and, if not immediately treated,
could result in death or permanent impairment to the member’s
health
o Nonemergency ambulance transportation is a scheduled or
unscheduled service in which the member requires attention by
EMT-trained personnel while in transit.
Ambulance types
There are two types of ambulance transports:
o Ground ambulance—an equipped and staffed land or water
vehicle designed to transport a member in the supine position
o Air ambulance—an equipped and staffed aircraft necessary to
West Virginia Medicaid, UniCare Health Plan of West Virginia, Inc.
Reimbursement Policy: Transportation Services: Ambulance and Nonemergent Transport
January 2015
Page 160 of 160

rapidly transport a member to the nearest appropriate facility
that could not otherwise be accomplished or be accessed by a
ground ambulance without endangering the member’s health.
Air ambulances are either rotary-wing (helicopter) or fixedwing (commercial or private aircraft)
Medical transport services
Medical transport services, also referred to as nonemergency
medical transport, entails the transport of a member by
nonmedically skilled personnel (i.e., laypersons) to receive covered
services. There are several types of medical transports:
ambulette/medi-van, wheelchair van, invalid coach, taxicab, minibus and public transportation (i.e., bus and/or subway).
Transportation modifiers: Single alpha characters with distinct
definitions that are paired together to form a two-character
modifier; the first character indicates the origination of the member,
and the second character indicates the destination of the member.
General Reimbursement Policy Definitions
Related policies

Portable/mobile radiology services
Related materials

None

