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Allergy Professional Payment Policy

The following payment policy applies to Tufts Medicare Preferred HMO contracted providers who render professional services in an outpatient or office setting. Note: Audit and disclaimer information is located at the end of this document.

Policy

Tufts Health Plan Medicare Preferred reimburses medically necessary allergy services.

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 Information1

Member eligibility can be verified electronically and detailed benefit coverage may be verified by contacting Tufts Health Plan Medicare Preferred Provider Relations. Tufts Medicare Preferred HMO follows Medicare coverage guidelines. Tufts Health Plan cannot cover items and services not covered under the CMS-approved Tufts Medicare Preferred HMO benefit plan. Tufts Medicare Preferred HMO's benefit plan currently covers a limited number of non-Medicare covered items as supplemental benefits. Note: Supplemental benefits are subject to change each year.

Member Responsibility

Tufts Medicare Preferred HMO members are not subject to an allergy copayment. 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

Reference the Authorization Policy for specific referral and authorization requirements. Some procedures may require prior authorization with the Tufts Health Plan Precertification Department. Reference the Tufts Medicare Preferred HMO Prior Authorization List for a list of procedures, services and items requiring prior authorization for Tufts Medicare Preferred HMO members. For a complete description of Tufts Medicare Preferred HMO's authorization requirements, reference the Authorization section within the Tufts Medicare HMO Preferred Provider Manual.

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Eligibility is subject to retroactive reporting of disenrollment.

Originated 11/2002, Revised 09/2011 2133522

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Tufts Medicare Preferred HMO Allergy Payment Policy

Billing Information

· · Submit the most updated industry standard codes. Physicians 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.

· ·

Note: Annually and quarterly, HIPAA medical code sets2 and modifiers 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 Medicare Preferred 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 95071 Inhalation bronchial challenge testing with antigens or gases, specify 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 Medicare Preferred HMO Allergy 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 95133 95134 95144 95145 95146 95147 95148 95149 95165 95170 95180 95199 Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; four stinging insect venoms Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; five stinging insect venoms Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; single stinging insect venom Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; two single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; three single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; four single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; five single stinging insect venoms Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; single or multiple antigens Professional services for the supervision or preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other anthropod Rapid desensitization procedure, each hour Unlisted allergy/clinical immunologic service or procedure

Reimbursement Information

Providers are reimbursed according to the Tufts Medicare Preferred HMO network contracted rates regardless of 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, and National Correct Coding Initiative (CCI). Tufts Health Plan allows up to 200 allergy tests combined within 365 days, to cover the percutaneous and intradermal tests for a patient's evaluation. Daily maximums apply. Allergy testing CPT procedure codes 95004-95024 will not be reimbursed when billed with CPT procedure code 95027.

Originated 11/2002, Revised 09/2011

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Tufts Medicare Preferred HMO Allergy Payment Policy

Allergy testing CPT procedure codes 95004-95075 will not be reimbursed when billed with Allergy Immunotherapy CPT procedure codes 95115-95134 or 95180-95199 on the same date of service. Note: CPT procedure codes 95004, 95024, and 95044 are not reimbursable by Tufts Health Plan Medicare Preferred when performed in an 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 physician's personal professional services in the course of diagnosis or treatment of an illness or injury. Evaluation and management CPT procedure codes (99201-99499) are not separately reimbursable 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 Medicare Preferred does not separately reimburse the physician 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 Medicare Preferred. The SOA indicates status of claims payments, denials and pending claims. If the procedure code(s) submitted is not used in processing, the SOA will reflect the actual procedure code(s) utilized by Tufts Health Plan Medicare Preferred to process the claim. 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. When an industry-standard code(s) is submitted and accepted by Tufts Health Plan Medicare Preferred, the electronic remittance advice will reflect the code(s) submitted and the actual procedure code(s) utilized by Tufts Health Plan for claims processing.

Document History

March 2009: Moved Tufts Medicare Preferred information to its own document. January 2010: Removed references to the Tufts Medicare Preferred PPO product. March 2011: Reviewed document for clarity; no content changes made. September 2011: Reviewed policy, no content changes

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. This policy provides information on Tufts Health Plan Medicare Preferred 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.

Originated 11/2002, Revised 09/2011

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Tufts Medicare Preferred HMO Allergy Payment Policy

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Allergy Professional Payment Policy

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