Certain tests should be billed as medically necessary for members with individual plans

Among the many changes brought about by the Affordable Care Act is the number of different health plans that members have to choose from, as well as the required benefit levels for those plans. In an article in the August Record, we discussed the topic of essential health benefits — benefits for such things as screenings for cancer and diabetes, vaccinations and chronic condition management. A plan’s coverage of essential health benefits is one factor in determining if it’s a qualified health plan under the Affordable Care Act.

It’s important to keep in mind that the type of health plan a member has often determines how a benefit is processed. For example, here are several services that are commonly performed during health maintenance exams:

• Chest X-rays
• Complete blood counts
• Prostate-specific antigens
• Electrocardiograms
• Urinalysis

Sometimes, these services will be coded as preventive, when billed with associated screening diagnosis codes. However, for members in BCBSM’s 2014 individual plans purchased on or off the marketplace, they should be coded as medically necessary diagnostic tests in order to be covered and paid, subject to cost-sharing. The diagnostic tests should be billed with the related medical diagnosis codes.

Note: These requirements apply to all individual market BCBSM products, including non health care-compliant plans and plans purchased on the Marketplace. Additionally, documentation of medical necessity must be included in the medical record to support this information, according to national coding guidelines.

How would you know that a member has an individual plan purchased on or off the marketplace? Members with this coverage have an alpha prefix of JXI, XYE or XYG on their BCBSM ID card.

These particular services have different billing requirements based on which plan a member has, so it’s extremely important that you continue to check your patients’ benefits and eligibility on web-DENIS or CAREN.

For more information about these changes, contact your BCBSM provider consultant.