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OhioBWC - Basics: (Policy library) - File

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.

 

 

 

 


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