Policy
and Procedure Name:
|
Pricing
Override Process
|
Policy
#:
|
MP-16-01
|
Code/Rule
Reference:
|
N/A
|
Effective
Date:
|
06/06/2014
|
Approved:
|
Freddie
Johnson, Esq., Chief of Medical Services (Signature on file)
|
Origin:
|
Medical
Policy
|
Supersedes:
|
All
policies, procedures, directives and memos (specifically the memo issued
03/01/2012) regarding pricing overrides that predate the effective date of this
policy.
|
History:
|
New
|
Review
date:
|
06/06/2019
|
I.
POLICY PURPOSE
The
purpose of this policy is to ensure that BWC provides the necessary information
to MCOs for completion of documentation and provision of appropriate EOB codes
for a pricing override process.
II.
APPLICABILITY
This
policy applies to MCOs.
III.
DEFINITIONS
None
IV.
POLICY
A. For pricing overrides,
it is the policy of BWC:
1. To have BWC
process MCO requests for payment above fee schedule from the following provider
types:
a. Certified
in-state providers;
b. Certified
out-of-state providers;
c. Non-certified
in-state providers;
2. To have BWC
verify requests via a retrospective audit and not require MCOs to obtain front-end
approval from BWC for:
a. Non-certified
out of state providers for payment over fee schedule;
b. Requests for
pricing codes designated as By Report/Not Routinely Covered.
B.
It
is the policy of BWC to require MCOs to document/include, at a minimum, the following
in all claims for which a pricing override is being requested:
1. How Miller
criteria is met;
2. Supporting
documentation;
3. Research that
confirms the correct code was billed;
4. Cost analysis information;
5. Negotiation
attempts; and
6. Clinical
rationale for authorization.
C.
The
MCO is responsible for maintaining all supporting documentation for pricing
override requests.
V.
Procedure
A.
MCOs
shall maintain supporting documentation for all pricing override requests.
B.
For
pricing override requests requiring BWC front-end approval, the MCO shall
submit the completed Pricing Override template to the MedPol email box.
C.
For
pricing override requests not requiring BWC front-end approval, the MCOs shall:
1. Create a note
entitled “MCO code and fee approval” with the following information, at a
minimum:
a. Date of service;
b. Description of
service with code;
c. Description of
how Miller criteria is met;
d. MCO approved
amount per code;
e. Provider name;
and,
f. Bill type (e.g.,
professional, ASC, outpatient, inpatient).
2. For the
following:
a. Codes designated
as By Report/Not Routinely Covered that exceed $10,000 (ten thousand); or,
b. By Report
vocational rehabilitation codes:
c. Submit the
following:
i. An explanation
detailing why the MCO is approving payment;
ii. Supporting
documentation;
iii. Bill containing EOB
752 and all applicable EOBs from the following list, indicating the services
and circumstances related to the authorization:
a) 787 –
Prosthetics
b) 788 – J3490 Unclassified
drugs
c) 789 – Unlisted
CPT codes
d) 790 – Unlisted
HCPCS codes
e) 791 – Other
coded services/procedure requiring EOB 752 override
f) 792 – Out-of-state
non-certified provider payment above fee schedule (used in addition to EOB 860
for BR/NC/NRC codes); and,
iv. Bill containing EOB
717 with:
a) An email to
MB&A with EOB 717 listed in the subject line;
b) Detailed
instructions, including manual pricing instructions, in a secured document
emailed to the MBASUPV email box.
c) Both MB&A and
the MCO, for auditing purposes, shall maintain supporting documentation for
bills processed using EOB 717.