NEW Superior Clinical and Payment Policies

Date: 09/08/17

Superior HealthPlan will be implementing several new clinical and payment policies for providers that serve the following members:

• Ambetter from Superior HealthPlan
• CHIP
• Medicaid (STAR, STAR+PLUS, STAR Kids and STAR Health)
• STAR+PLUS Medicare-Medicaid Plan (MMP)
• Superior HealthPlan Medicare Advantage (HMO and HMO SNP)

The following policies are scheduled for implementation on 10/08/17 for MMP and Medicare Advantage Programs, and 12/15/17 for Ambetter, Medicaid and CHIP Programs (as applicable).   

Please note: Clinical and payment policies are applicable to all providers delivering services to Superior HealthPlan members, whether or not the provider is contracted with Superior.

Payment Policies

Professional Claims for Non-Emergent Emergency Room Services –Superior’s claims processing system will use a coding algorithm strategy to automatically adjudicate emergency department claims based on the applicable ED claim category in accordance with the diagnosis code appearing on the claim.  This categorization system classifies emergency department visits into emergent and non-emergent categories. 

When a physician bills a level 4 (99284) or level 5 (99285) emergency room service, with a non-emergent diagnosis, Superior will reimburse the provider at a level 3 (99213) reimbursement rate.

Physician's Consultation Services (Ambetter Only) –Superior will reimburse consultation codes at the corresponding E&M visit level.  The provider should bill the E&M code (other than the consultation code) that describes the service provided. 

Upon receipt of the claim, Superior will identify consultation codes 99241-99255 and crosswalk them to the more appropriate level of office visit, established patient or subsequent hospital care procedure code. The provider will be paid according to the fee schedule for the equivalent procedure code.

Please note:  Retrospective post-payment review may be performed for Medicaid and CHIP claims to validate appropriate billing.

Problem Oriented Visits with Preventative Visits (Ambetter, MMP and Medicare Advantage Only)  –Superior will conduct a clinical claims review of E&M coding combinations when a problem-oriented visit is billed with a preventative visit, regardless if modifier -25 is present.  If the problem-oriented visit is appended with modifier -25 or without modifier -25 and clinical claims review supports a significant and separately identifiable E&M service; Superior will reimburse the preventative medicine code plus 50 percent of the problem-oriented E&M code.

Please note:  Retrospective post-payment review may be performed for Medicaid and CHIP claims to validate appropriate billing.

Problem Oriented Visits Billed with Surgical Procedures (Ambetter, MMP and Medicare Advantage Only) –Superior will conduct a clinical claims review of E&M and surgery coding combinations when a problem-oriented visit is billed with a surgical procedure with a -0, -10 or -90 day global surgical procedure regardless if the modifier -25 is present.

If the problem-oriented visit is appended with modifier -25 or without modifier -25, and clinical claims review supports a significant and separately identifiable E&M service; Superior will reimburse the surgical procedure plus 50 percent of the problem-oriented E&M code.

If the E&M service resulted in the decision to perform surgery, then modifier -57 should be appended to the E&M procedure code for consideration of payment when the decision for surgery was made within the global surgical period.

Please note:  Retrospective post-payment review may be performed for Medicaid and CHIP claims to validate appropriate billing.

Urine Specimen Validity Testing  –Superior will disallow separate reimbursement for testing to confirm that a urine drug specimen is unadulterated.  Validity testing is an internal control process that is not separately reportable.

Clinical Policies

Non-Invasive Testing for Rupture of Fetal Membranes (PROM Testing) - It is the policy of Superior HealthPlan that non-invasive testing for rupture of fetal membranes is considered not medically necessary for members as it has not been shown to improve clinical outcomes over standard methods of diagnosis.. 

To view all of Superior’s clinical and payment policies, please visit the Superior Clinical & Payment Policies web page.

For any questions on these policies, providers may reach out to their local Account Manager, or contact Provider Services at 1-877-391-5921.