MD| The Maryland Insurance Administration issued Bulletin 25-4, addressing the coding and coverage of preventive services without cost-sharing for health insurers, nonprofit health service plans, and health maintenance organizations (HMOs). It reminds carriers of their obligations under federal and state laws, particularly in light of recent FAQs issued by federal departments. The bulletin emphasizes the importance of proper coding for preventive services, outlines Maryland laws related to coding guidelines and clean claims, and provides guidance on how carriers should process claims for preventive services to ensure compliance with regulations.
Key points:
- Carriers must provide coding guidelines to healthcare providers and educate them on proper coding of preventive services to avoid improper cost-sharing for patients.
- Preventive services can be indicated through CPT codes, Modifier 33, or ICD-10 diagnosis codes with the prefix “Z”.
- Carriers must process clean claims within 30 days and can only request additional information to determine if a service is preventive in accordance with specific regulations.
- Cost-sharing applied to preventive services due to incorrect coding should be promptly reversed upon appeal or documentation showing the service was preventive.