Updated Payment Policies Effective 5/1/22

Date: 03/31/22

Effective 5/1/22, Arizona Complete Health will add the policies outlined in the table below as reimbursement edits within our claims adjudication system.

The policies are developed based on medical literature and research, industry standards and guidelines as published and defined by the American Medical Association’s Current Procedural Terminology (CPT®), Centers for Medicare and Medicaid Services (CMS), and public domain specialty society guidance.

Visit our Policy Page to find the entire policy. The policy number, name and brief description are included in the table below.

Number	Policy Name	Policy Summary Description	Line of Business
CC.PP.052	Problem Oriented Visits with Surgical Procedures	A physician or other qualified health professional may submit both a problem-oriented E&M CPT® code and a surgical procedure code on the same date of service for the same member. Once clinically validated (see CC.PP.013 “Clinical Validation of Modifier -25”) if the problem-oriented E&M represents a significant and separately identifiable E&M procedure or service, the problem-oriented procedure code will be reimbursed at a reduced rate.	Medicare
CC.PP.501	30 Day Readmission	The policy is based in part on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission. If a readmission is determined to have been inappropriate or preventable according to the clinical review guidelines outlined in the policy, payment will be denied. The policy outlines examples of scenarios that are included and scenarios that are excluded.	Marketplace

Number

Policy Name

Policy Summary Description

Line of Business

CC.PP.052

Problem Oriented Visits with Surgical Procedures

A physician or other qualified health professional may submit both a problem-oriented E&M CPT® code and a surgical procedure code on the same date of service for the same member. Once clinically validated (see CC.PP.013 “Clinical Validation of Modifier -25”) if the problem-oriented E&M represents a significant and separately identifiable E&M procedure or service, the problem-oriented procedure code will be reimbursed at a reduced rate.

Medicare

CC.PP.501

30 Day Readmission

The policy is based in part on the methodology set forth in the Quality Improvement Organization Manual, CMS Publication 100-10, Chapter 4, Section 4240, for determining an inappropriate readmission.

If a readmission is determined to have been inappropriate or preventable according to the clinical review guidelines outlined in the policy, payment will be denied. The policy outlines examples of scenarios that are included and scenarios that are excluded.

Marketplace

If you have questions, please contact your Provider Engagement Specialist. If you need your assigned Provider Engagement Specialist’s contact information, please email us at AzCHProviderEngagement@azcompletehealth.com.