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Allergy Professional Payment Policy

The following payment policy applies to Tufts Health Plan commercial contracted providers who render professional services in an outpatient or office setting. This policy applies to commercial products. For information on Tufts Medicare Preferred HMO's policies and procedures, click here. Note: Audit and disclaimer information is located at the end of this document.

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Policy

Tufts Health Plan covers medically necessary allergy services, as described below.

Definition

Allergy testing is defined as identifying the offending antigen(s) for a patient by in-vivo testing percutaneous, intradermal, patch, photo patch tests, and photo tests). Immunotherapy (desensitization, hyposensitization) is defined as the parenteral administration of allergenic extracts as antigens at periodic intervals, usually on an increasing dosage scale to a dosage maintained as maintenance therapy. Indications for immunotherapy are determined by appropriate diagnostic procedures coordinated with clinical judgment and knowledge of the natural history of allergic diseases.

General Benefit Information 2

Services and subsequent payment are based on the member's benefit plan document. Providers and their office staff are required to use self-service channels to verify effective dates and copayments for commercial members prior to initiating services. Refer to the Electronic Services section of our website for our self-service channel options. Benefit specifics should be verified prior to initiating services by logging on to our website or by contacting Provider Services.

Member Responsibility

Allergy injections are subject to an allergy copayment. A deductible and/or coinsurance may apply based on the member's allergy benefit coverage. Note: An office visit copayment may apply, depending on the member's benefit plan specifics. Tufts Health Plan recommends not billing the member for the coinsurance and/or deductible amount until the claim has processed so that the appropriate member responsibility can be determined. Both the provider's Statement of Account (SOA) and the Electronic Remittance Advice (ERA) will reflect the member's responsibility amount.

Authorization Requirements

Services Requiring Prior Authorization While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you will need to make sure that prior authorization has been obtained. Refer to the Authorization Policy for specific referral and authorization requirements. Some procedures require prior authorization with the Tufts Health Plan Precertification Department. Refer to the Clinical Resources section of our website for a list of procedures, services and items that require

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Commercial products include HMO, POS, PPO & CareLinkSM when Tufts Health Plan is Primary Administrator. Eligibility is subject to retroactive reporting of disenrollment.

Originated 11/2002, Revised 09/2011 2092026

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Tufts Health Plan ­Allergy Professional Payment Policy

prior authorization. Refer to the CareLink Prior Authorization List for a list of procedures, services and items requiring prior authorization for CareLink members. For a complete description of Tufts Health Plan's commercial authorization requirements, refer to the Authorization section within the Tufts Health Plan Commercial Provider Manual.

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Billing Information

Submit the most updated industry-standard codes. Submit a modifier, when applicable, with the corresponding CPT and/or HCPCS procedure code(s). For more information regarding modifiers refer to the Modifier Payment Policy. Providers must bill for antigen services using only the component CPT procedure codes: 95115 or 95117 (injection only) and/or 95144-95170 (representing antigens and their preparation). Submit CPT procedure code 95115 or 95117 when providing only an injection service. Submit procedure code range 95144-95170 when providing only the antigen/antigen preparation.

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Note: Annually and quarterly, HIPAA medical code sets undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-9 diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes. EDI Claim Submitter Information · Submit claims in HIPAA compliant 837P format for professional services. Claims billed with nonstandard codes will reject if billed electronically. Paper Claim Submitter Information · Submit claims on a CMS-1500 form for professional services. Claim line(s) billed with non-standard codes will deny. Allergy Testing CPT Procedure Codes: Procedure Description Codes 95004 Percutaneous tests with allergenic extracts, immediate type reaction Percutaneous tests sequential and incremental, with drugs, biologicals or venoms, 95010 immediate type reaction Intracutaneous tests, sequential and incremental, with drugs, biologicals, or venoms, 95015 immediate type reaction 95024 Intracutaneous tests with allergenic extracts, immediate type reaction Intracutaneous tests, sequential and incremental, with allergenic extracts for airborne 95027 allergens, immediate type reaction 95028 Intracutaneous tests with allergenic extracts, delayed type reaction, including reading 95044 Patch or application test(s) 95052 Photo patch test(s) 95056 Photo tests Inhalation bronchial challenge testing with histamine, methacholine, or similar 95070 compounds Inhalation bronchial challenge testing with antigens or gases, specify 95071 95075 Ingestion challenge test

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HIPAA medical code sets include HCPCS, CPT Procedure and ICD-9 diagnosis codes.

Originated 11/2002, Revised 09/2011

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Tufts Health Plan -- Allergy Professional Payment Policy

Allergy Immunotherapy CPT Procedure Codes: Procedure Description Codes Professional services for allergen immunotherapy not including provision of allergenic 95115 extracts; single injection Professional services for allergen immunotherapy not including provision of allergenic 95117 extracts; two or more injections Professional services for allergen immunotherapy in prescribing physicians office or 95120 institution, including provision of allergenic extract; single injection Professional services for allergen immunotherapy in prescribing physicians office or 95125 institution, including provision of allergenic extract; two or more injections Professional services for allergen immunotherapy in prescribing physicians office or 95130 institution, including provision of allergenic extract; single stinging insect venoms Professional services for allergen immunotherapy in prescribing physicians office or 95131 institution, including provision of allergenic extract; two stinging insect venoms Professional services for allergen immunotherapy in prescribing physicians office or 95132 institution, including provision of allergenic extract; three stinging insect venoms Professional services for allergen immunotherapy in prescribing physicians office or 95133 institution, including provision of allergenic extract; four stinging insect venoms Professional services for allergen immunotherapy in prescribing physicians office or 95134 institution, including provision of allergenic extract; five stinging insect venoms Professional services for the supervision of preparation and provision of antigens for 95144 allergen immunotherapy, single dose vial(s) Professional services for the supervision or preparation and provision of antigens for 95145 allergen immunotherapy; single stinging insect venom Professional services for the supervision or preparation and provision of antigens for 95146 allergen immunotherapy; two single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for 95147 allergen immunotherapy; three single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for 95148 allergen immunotherapy; four single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for 95149 allergen immunotherapy; five single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for 95165 allergen immunotherapy; single or multiple antigens Professional services for the supervision or preparation and provision of antigens for 95170 allergen immunotherapy; whole body extract of biting insect or other anthropod 95180 Rapid desensitization procedure, each hour 95199 Unlisted allergy/clinical immunologic service or procedure

Compensation/Reimbursement Information

Providers are reimbursed according to the Tufts Health Plan network physician compensation or contracted rates regardless of the address where the service is rendered. Claims are subject to payment edits that are updated at regular intervals and generally based on CMS, specialty society guidelines, drug manufactures' package label inserts, and National Correct Coding Initiative (CCI). Allergy Tests Tufts Health Plan allows up to 200 allergy tests (percutaneous and intradermal combined) within 365 days, to cover the percutaneous and intradermal tests for a patient's evaluation. Daily maximums apply. Refer to the Maximum Units Payment Policy on our website for information on maximum units.

Originated 11/2002, Revised 09/2011

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Tufts Health Plan -- Allergy Professional Payment Policy

Allergy Testing and Immunotherapy Tufts Health Plan will not compensate for allergy testing CPT procedure codes 95004-95075 when billed with allergy immunotherapy CPT procedure codes 95115-95134 or 95180 on the same date of service. Note: Tufts Health Plan will not compensate for CPT procedure codes 95004, 95024, 95044, 95052 and 95056 when performed in an emergency room, outpatient or inpatient setting as they are considered to be incident to the service. CMS defines "incident to" services as those furnished as an integral, although incidental, part of the provider's personal professional services in the course of diagnosis or treatment of an illness or injury. Evaluation and Management with Allergen Immunotherapy Tufts Health Plan does not separately compensate for evaluation and management CPT procedure codes (99201­99499) in addition to allergen immunotherapy (95004-95199), unless there are other identifiable services provided and documented at that time. Services must be substantive to qualify for payment and supplementary to those routinely provided with allergen injections. Submit these services using the appropriate modifier. Tufts Health Plan does not separately reimburse the provider for time and direct costs associated with procuring and maintaining inventories of drugs and supplies. This practice expense is a component of the existing reimbursement schedule. Statement of Account (SOA) The SOA is sent to all providers to provide information on the status of the claim(s) submitted to Tufts Health Plan. The SOA indicates status of claims payments, denials and pending claims. Effective January 1, 2012, paper Statements of Account and the Summary of Account on Tufts Health Plan's secure Provider website will no longer display embedded procedure code modifiers or any Tufts Health Plan unique characters. Electronic Remittance Advice (ERA) The HIPAA compliant 835 ERA is an EDI transaction that providers may request to electronically post paid and denied claims information to their accounts receivable system.

Document History

February 2008: Revised general benefit information with self-service channels information April 2009: Removed the following edit: Allergy testing CPT procedure codes 95004-95024 will not be reimbursed when billed with CPT procedure code 95027. This is no longer effective. December 2009: Reviewed without changes. October 2011: Reviewed policy. Template updates, added information regarding paper SOAs and the Summary of Account on Tufts Health Plan's secure Provider website effective January 1, 2012. March 2012: Updated CareLink disclaimer language April 2012: Template updates

Audit and Disclaimer Information

Tufts Health Plan reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in this payment policy. If such an audit determines that your office/facility did not comply with this payment policy, Tufts Health Plan will expect your office/facility to refund all payments related to non-compliance.

Originated 11/2002, Revised 09/2011

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Tufts Health Plan -- Allergy Professional Payment Policy

This policy provides information on Tufts Health Plan claims adjudication processing guidelines. As every claim is unique, the use of this policy is not a guarantee of payment nor a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization and utilization management guidelines when applicable, adherence to plan policies and procedures and claims editing logic. This policy does not apply to Tufts Medicare Preferred HMO or the Private Health Care Systems (PHCS) network (also known as Multiplan). This policy applies to CareLink for providers in the Massachusetts and Rhode Island service areas. Providers in the New Hampshire service area are subject to Cigna's provider agreements with respect to CareLink members.

Originated 11/2002, Revised 09/2011

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Tufts Health Plan -- Allergy Professional Payment Policy

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