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For SWH of MA Members About Molina

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Molinalogo

Payment Integrity Policies

A

Policy Number	Policy Name	Effective Date	Link
C13	ADD-ON Code	11/01/2020	View Policy
PI99	Advance Beneficiary Notice (ABN) Modifiers GA, GX, GY and GZ	1/4/2024	View Policy
PI54	After Hours and Weekend Care Professional	8/1/2023	View Policy
PI111	Allergy Test	01/04/2023	View Policy
C14	Ambulance Modifier Coding Policy	11/01/2020	View Policy
PI120	Ambulatory Echocardiograph Monitoring	01/04/2024	View Policy
PI108	Anesthesia Bundling	01/04/2023	View Policy
PI121	Annual Wellness Visit sooner than eleven whole months following Initial (IPPE)	01/04/2023	View Policy
PI122	Aortography and Peripheral Angiography	01/04/2023	View Policy
PI34	Appropriate Level of Care Reimbursement	01/07/2022	View Policy
PI119	Autonomic Function Testing	01/04/2023	View Policy

B

Policy Number	Policy Name	Effective Date	Link
PI102	BRCA1 and BRCA2 Genetic Testing	01/04/2023	View Policy
PI35	Breast Cancer Genetic Testing Tier 1 vs Tier 2	01/04/2023	View Policy

C

Policy Number	Policy Name	Effective Date	Link
PI97	CMS Replacement Codes	09/11/2023	View Policy
PI98	Colonoscopy and Sigmoidoscopy	09/11/2023	View Policy
PI42	Corrected Claims	10/21/2022	View Policy
PI53	Co-Surgeon_Team-Surgeon	09/01/2023	View Policy
PI38	Critical Care Codes when Discharging Home from the Emergency Department	08/04/2022	View Policy
PI93	CT (Computed Tomography) of the Abdomen and Pelvis	09/11/2023	View Policy

D

Policy Number	Policy Name	Effective Date	Link
C16	Decision for Surgery Modifier 57 Coding Policy	11/01/2020	View Policy
PI59	Discontinued Procedures	04/06/2023	View Policy
PI65	DME KF Modifier	08/01/2023	View Policy
PI73	DME Non-Invasive Ventilator Settings	06/21/2023	View Policy
PI90	DME Place of Service 31 or 32	09/11/2023	View Policy
PI123	DME Place of Service separately reimbursable	09/11/2023	View Policy
PI124	DME Rental Vs Purchase	12/01/2023	View Policy
PI25	DRG Clinical Validation	01/07/2022	View Policy
PI45	Duplicate Claims	11/01/2022	View Policy

E

Policy Number	Policy Name	Effective Date	Link
CXX	Emergency E&M Codes and Place of Service 23	Coming Soon	Coming Soon
CXX	ESRD Billing for J0406 or J0606 with Modifier AX	Coming Soon	Coming Soon
C24	Excludes1 Note Coding Policy	11/01/2020	View Policy

F

Policy Number	Policy Name	Effective Date	Link
PI39	Facility Emergency Department Evaluation and Management leveling	08/15/2022	View Policy
PI80	Fee Schedule	09/01/2023	View Policy

G

Policy Number	Policy Name	Effective Date	Link
C0	General Coding Policy	11/01/2020	View Policy
PI51	Global Surgical Packages	09/01/2023	View Policy

H

Policy Number	Policy Name	Effective Date	Link
PI56	High Dollar Pharmacy	08/01/2023	View Policy
PI37	High Level Evalution and Managment with Preventive Medicine	10/18/2022	View Policy
CXX	Hospice Value Code 61	Coming Soon	Coming Soon
PI70	Hospice	01/01/2023	View Policy
PI01	Hospital Routine Supplies Services	12/01/2017	View Policy
PI36	Hydrolyzed Enteral Formula Diagnosis	01/01/2023	View Policy

I

Policy Number	Policy Name	Effective Date	Link
C20	ICD-10 First Listed Diagnosis Coding Policy	11/01/2020	View Policy
C3	ICD-10 Specificity Coding Policy	11/01/2020	View Policy
C18	Image Guided Radiation Therapy Coding Policy	11/01/2020	View Policy
PI77	Injection and Infusions in the ER with 25 Modifier	09/01/2023	View Policy
PI71	Inpatient services billed on Outpatient bill types	09/01/2023	View Policy
PI125	Interim Hospital Claims	01/02/2024	View Policy

J

Policy Number	Policy Name	Effective Date	Link

K

Policy Number	Policy Name	Effective Date	Link

L

Policy Number	Policy Name	Effective Date	Link
C4	Lab Codes with Modifiers 59 and 91 Coding Policy	11/01/2020	View Policy
C17	Lab Panel Coding Policy	11/01/2020	View Policy
PI101	Labs Overlapping with Facility	09/25/2023	View Policy

M

Policy Number	Policy Name	Effective Date	Link
PI126	Medical Supplies Home Health Consolidated Billing	01/02/2024/td>	View Policy
C15	Medically Unlikely Edits Coding Policy	11/01/2020	View Policy
Cxx	Modifer 25 Coding Policy	coming soon/td>	coming soon
C5	Modifer 26 Coding Policy	11/01/2020	View Policy
C6	Modifier KK Coding Policy	11/01/2020	View Policy
C7	Modifier TC Coding Policy	11/01/2020	View Policy
PI131	Modifiers XE XS XP XU and 59 Usage	01/02/2024/td>	View Policy
PI94	Molecular Pathology	09/25/2023	View Policy
PI118	Molina Healthcare Audit.Recovery Policy for Diagnosis Codes	01/02/2024/td>	View Policy
PI115	Molina Healthcare: Audit/Recovery Policy for Revenue to CPT Code Review	01/02/2024/td>	View Policy
PI113	Molina Healthcare Audit/Recovery Policy: Variable Discount Payments for Providers	01/02/2024	View Policy
PI116	Molina Healthcare Audit Recovery Policy for Billed Units	01/02/2024	View Policy
PI117	Molina Healthcare Audit.Recovery Policy for CPT to CPT Code	01/02/2024/td>	View Policy
PI66	Molina Healthcare Billing Requirements	06/01/2023	View Policy
PI112	Molina Healthcare Cross-Departmental Audit and Recovery Policy	01/02/2024/td>	View Policy
PI67	Multiple EM codes for the same provider same date of service	09/01/2023	View Policy
PI127	Multiple Procedure Payment Reduction	01/02/2024	View Policy

N

Policy Number	Policy Name	Effective Date	Link
C12	NCCI PTP with Modifiers Coding Policy	11/01/2020	View Policy
PI44	NDC	11/01/2022	View Policy
PI32	Newborn and NICU	01/07/2022	View Policy
PI83	Non-Invasive Abdominal/Visceral Vascular Studies	09/25/2023	View Policy
C19	Non-Invasive Prenatal Testing Coding Policy	11/01/2020	View Policy
PI128	NPFS Status Indicator T	01/02/2024	View Policy

O

Policy Number	Policy Name	Effective Date	Link
PI50	Observation	06/01/2023	View Policy
PI110	Opioid Treatment Service	01/02/2024	View Policy
PIXX	Optum Pause and Pay/td>	coming soon	Coming Soon
PI33	Outpatient Definitive Drug Testing	09/01/2021	View Policy
PI84	Overlapping Room and Board	09/25/2023	View Policy

P

Policy Number	Policy Name	Effective Date	Link
C10	Packaged and conditionally packaged lab services Coding Policy	11/01/2020	View Policy
PI129	Paid Amount Exceeded Billed Amount	1/02/2024	View Policy
PI130	Physical Therapy Max Units Per Day	1/02/2024	View Policy
PI106	Physician Office Laboratory Testing	10/18/2022	View Policy
PI172	Podiatric Q Modifiers	09/25/2023/td>	View Policy
PI104	Polysomnography Studies and Home Sleep Testing	09/25/2023	View Policy
PI48	Post-Pay Authorization Audit	06/01/2023	View Policy
PI00	Post Pay General Policy	06/01/2023	View Policy
PI96	Presumptive and Definitive Drug Testing Limitation	09/25/2023	View Policy
PI47	Psychotherapy Add On with High Level EM	10/18/2022	View Policy
PI105	PT/OT Initial Evaluations	09/25/2023	View Policy
PI87	PT/OT/ST Yearly Limit	09/25/2023	View Policy
PI68	Pulmonary Function Testing	09/25/2023	View Policy

Q

Policy Number	Policy Name	Effective Date	Link

R

Policy Number	Policy Name	Effective Date	Link
PI88	Radiology Bone Density	09/25/2023	View Policy
PI95	Radiology for Chest	09/25/2023	View Policy
PI41	Readmission	06/01/2023	View Policy
PI60	Reduced Services and Discontinued Procedures	07/10/2023	View Policy
PIXX	Repeat Procedure Modifiers 76 & 77.	Coming Soon	Coming Soon
PI103	Respiratory Pathogen Panel Test	09/25/2023	View Policy

S

Policy Number	Policy Name	Effective Date	Link
PI91	Self-Administered Drugs	01/07/2022	View Policy
PI57	Semiprivate Vs Private Room	09/25/2023	View Policy
PI26	Sepsis	01/07/2022	View Policy
PI99	Specimen Validity Testing	09/25/2023	View Policy
PI46	Split-Night-Sleep-Study	10/18/2022	View Policy
PI92	Status Indicator Flag B Bundled Codes	09/25/2023	View Policy
PI89	STI Lab Panel Testing	09/25/2023	View Policy

T

Policy Number	Policy Name	Effective Date	Link
PI82	Tendon Injections Missing Diagnosis	09/01/2023	View Policy
C10	Therapy Modifier Coding Policy	11/01/2020	View Policy

U

Policy Number	Policy Name	Effective Date	Link
PI61	Unspecified Codes in an Inpatient Setting Policy	04/01/2022	View Policy

V

Policy Number	Policy Name	Effective Date	Link

W

Policy Number	Policy Name	Effective Date	Link

X

Policy Number	Policy Name	Effective Date	Link

Y

Policy Number	Policy Name	Effective Date	Link

Z

Policy Number	Policy Name	Effective Date	Link