Updated Payment Policies Effective January 1, 2021

Date: 11/05/20

We are happy to inform you that Sunflower Health Plan is publishing its payment policies to inform providers about acceptable billing practices and reimbursement methodologies for certain procedures and services. We will apply these policies as medical claims reimbursement edits within our claims adjudication system. This is in addition to all other reimbursement processes that Sunflower currently employs.

We believe that publishing this information will help providers to bill claims more accurately, therefore reducing unnecessary denials and delays in claims processing and payments. These policies address coding inaccuracies including diagnosis to procedure code mismatch, inappropriately modified procedures, unbundling, incidental procedures, duplication of services, medical necessity requirements and health plan specific payment rules for procedures and services.

These 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, unless specifically addressed in the fee-for-service provider manual published by the state of Kansas regulations.

Visit the Clinical and Payment Policies page on our website to find the Payment Policies. The effective date for the below policies is January 1, 2021.

Payment Policies for Medicare and Marketplace

• CC.PP.061 - Non-obstetrical and Obstetrical Transabdominal and Transvaginal Ultrasounds: Revision to the existing CC.PP.061 policy to include a multi-procedure reduction for transvaginal and first-trimester abdominal ultrasound performed on the same day. The transvaginal ultrasound would be paid at 100% and the abdominal ultrasound will be reduced by 50%.
•  CC.PP.067 - Renal Hemodialysis: Hemodialysis will be denied in excess of three units or visits during any calendar week.
•  CC.PP.068 - Multiple Procedure Payment Reduction for Therapeutic Services: When multiple (two or more) “always therapy” procedures with an MPI of 5 are performed by the same provider, or by providers within the same group practice, on the same day, the policy will allow 100% of the maximum allowance for the therapeutic procedure with the highest cost per until and 90% of the allowance for each subsequent therapeutic procedure.
•  CC.PP.069 - Multiple Procedure Reduction: Ophthalmology: When multiple (two or more) diagnostic ophthalmology procedures with an MPI of 7 are performed by the same provider, on the same patient, on the same day, the policy will allow 100% of the maximum allowance for the first diagnostic procedure with the highest cost per unit and 80% of the allowance for each subsequent diagnostic ophthalmology procedure unless the modifier -26 is present.