Anthem and UHC Make Changes to Several Testing Policies

June 2, 2023

Anthem Genetic Testing:
Starting June 1, 2023, Anthem will change its automated edits and simplify remittance messaging for claims received on CMS-1500 forms. The edits being put in place will promote faster claim processing and reduce follow-up audits and/or record requests for claims miscoded according to coding guidelines. Furthermore, there will be greater attention on identifying inappropriate billing of genetic testing services.  Listed below are examples of claim edits provided by Anthem and the policy can be found here:

•    Multianalyte Assays with Algorithmic Analyses (MAAA): CPT® 81507: This edit will deny laboratory provider claims submitted with the proprietary laboratory analysis code for the associated proprietary harmony prenatal test when the laboratory provider is not an affiliated proprietary laboratory.
•    Panel Testing: This edit will deny laboratory provider claims submitted with codes for individual components of a panel test (for example, tumors, inherited conditions, and hematologic malignancy) when a single panel code exists. Providers who believe their medical record documentation supports services billed should follow the claims payment dispute process (including submission of all supporting documentation with the dispute) as outlined in the provider manual.

UHC Reimbursement Policy Updates:
As of August 1, 2023, United Health Care (UHC) is updating their Molecular Pathology Test requirements for both professional and facility claims. A unique test ID obtained through the Genetic Test Registry (GTR) is no longer required, as they will now require the DEX Z codes.  These DEX Z codes can be obtained from the Palmetto DEX Registry.

In addition, effective August 1, 2023, UHC is updating their Anatomical Modifier Requirement Policy for Percutaneous Coronary Intervention Procedures (Professional).  New modifiers will be used to identify the different parts of the body where the specific percutaneous coronary intervention procedure is performed. 
•    LC (Left Circumflex Coronary Artery)
•    LD (Left Anterior Descending Coronary Artery)
•    LM (Left Main Coronary Artery), RC (Right Coronary Artery)
•    RI (Ramus Intermedius Coronary artery) are the new required modifiers. 

Lastly, as of August 1, 2023, UHC is updating their Age-Based Codes Policy.  Procedure codes submitted for members outside the appropriate age range for the codes will be ineligible for reimbursement.

For more information on these UHC policy changes, please click here.


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