Ambetter from Absolute Total Care Payment Policy and Edit Updates Effective 10/1/2021

Date: 07/30/21

Thank you for your continued partnership with Absolute Total Care. As you know, we continually review and update our payment and utilization policies to ensure that they are designed to comply with industry standards while delivering the best patient experience to our members. We are writing today to inform you of new policies Absolute Total Care will be implementing effective *10/1/2021*.

CC.PP.001 Prepay Edit	Edit Function	Edit Description	EX Code	Lines of Business
Procedure Modifier Revenue Necessary (PMRN)	The PMRN edit will deny procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (HCFA) and outpatient facility (UB-04) claims.	According to CMS and AMA, to facilitate claim processing and prevent claim denials, procedures which can be performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate. Therapy Claims: On professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such, must always be accompanied by one of the therapy modifiers. Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy. “Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code. CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when furnished by a therapist.	EX Code: we -Procedure Modifier Revenue Necessary	Marketplace

CC.PP.001 Prepay Edit

Edit Function

Edit Description

EX Code

Lines of Business

Procedure Modifier Revenue Necessary (PMRN)

The PMRN edit will deny procedures that require an associated modifier. The edit also identifies situations where a correct modifier and a correct revenue code are required. This edit applies to professional (HCFA) and outpatient facility (UB-04) claims.

According to CMS and AMA, to facilitate claim processing and prevent claim denials, procedures which can be performed on different sides of the body, separate anatomical areas, or separate patient encounters require the use of modifiers whenever appropriate.

Therapy Claims: On professional claims, each code designated as “always therapy” must always be furnished under an SLP, OT, or PT plan of care, regardless of who furnishes them; and, as such, must always be accompanied by one of the therapy modifiers.

Medicare recognizes the services furnished under the OPT services benefit as either “always” or “sometimes” therapy.

“Always therapy” codes require modifier GN, GO, or GP appended to the therapy CPT code.

CMS approved "sometimes therapy" codes require the appropriate modifier and revenue code combination when furnished by a therapist.

EX Code: we -Procedure Modifier Revenue Necessary

Marketplace

Policy	Policy Name	Lines of Business
NCD 20.8.3	Single Chamber and Dual Chamber Permanent Cardiac Pacemakers	Marketplace
NCD 150.3	Bone (Mineral) Density Studies	Marketplace
NCD 220.13	Percutaneous Image-Guided Breast Biopsy	Marketplace
NCD 210.1	Prostate Cancer Screening Tests	Marketplace
NCD 210.10	Screening for Sexually Transmitted Infections (STIs) and High-Intensity Behavioral Counseling (HIBC) to Prevent STIs	Marketplace
NCD 250.3	Intravenous Immune Globulin for the Treatment of Autoimmune Mucocutaneous Blistering Diseases	Marketplace
NCD 110.21A	Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions	Marketplace

For questions about this or any of our payment policies, please don’t hesitate to reach out to our Provider Services team at 1-833-270-5443.