Outpatient Imaging and Radiology Billing Manual

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General Benefit Policies

Providers must be enrolled as a Health First Colorado provider (Provider) in order to:

  • Treat a Health First Colorado member; and
  • Submit claims for payment to the Health First Colorado (Health First Colorado).

Imaging and radiology services are a benefit under the following conditions:

  1. Services must be authorized and supervised by a licensed physician.
  2. The services are performed to diagnose conditions and illnesses with specific symptoms.
  3. The services are performed to prevent or treat conditions that are Health First Colorado covered benefits.
  4. The services are not routine diagnostic tests performed without apparent relationship to treatment or diagnosis for a specific illness, symptom, complaint, or injury.
  5. Radiology services are performed by a provider with equipment certified by the Colorado Department of Public Health and Environment (CDPHE) and enrolled as a Health First Colorado Provider.

The Department of Health Care Policy and Financing (the Department) periodically modifies billing information. Therefore, the information in this manual is subject to change, and the manual is updated as new billing information is implemented.

Co-pays for Imaging and Radiology Procedures

  • There is a $1 co-pay per visit if the service is performed at an X-ray facility.
  • There is a $2 co-pay per visit if the service is performed at a medical clinic/office.
  • There is a $4 co-pay per visit if the service is performed at an outpatient hospital.

Providers must look up a member's Health First Colorado eligibility status to determine if that member is eligible for a co-pay on the date of service. Many members, including children ages 0-19 and pregnant women, are exempt from co-pay responsibilities.

Providers cannot refuse treatment to a member if the member is unable to immediately pay the co-pay. However, the member still remains liable for the co-pay at a later date. Reference Program Rule 8.754 for specific co-pay guidelines

Payment for Covered Services/Procedures

Regardless of whether Health First Colorado has actually reimbursed the provider, billing members for covered procedures is strictly prohibited. Balance billing is prohibited. If reimbursement is made, providers must accept this payment as payment in full (see Program Rule 8.012). The provider may only bill the member for procedures not covered by Health First Colorado.

  • Members may be billed for non-covered procedures in accordance with C.R.S. 25.5-4-301(1)(a)(I).
    • (1) (a) (I) Except as provided in section 25.5-4-302 and subparagraph (III) of this paragraph (a), no recipient or estate of the recipient shall be liable for the cost or the cost remaining after payment by Medicaid, Medicare, or a private insurer of medical benefits authorized by Title XIX of the social security act, by this title, or by rules promulgated by the state board, which benefits are rendered to the recipient by a provider of medical services authorized to render such service in the state of Colorado, except those contributions required pursuant to section 25.5-4-209 (1). However, a recipient may enter into a documented agreement with a provider under which the recipient agrees to pay for items or services that are nonreimbursable under the medical assistance program. Under these circumstances, a recipient is liable for the cost of such services and items.
  • If a PAR for procedures are required, the following policy applies:
    • Technical/lack of information (LOI) denial does not mean those procedures are not covered. Members may not be billed for procedures denied for LOI.
    • Procedures partially approved are still considered covered procedures. Members may not be billed for the denied portion of the request.
    • Procedures totally denied for not meeting medical necessity criteria are considered non-covered services.

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Covered Imaging and Radiology Procedures

Health First Colorado covers procedures including but are not limited to: angiograms, computed tomography (CT scans), electrocardiograms (ECG), magnetic resonance imaging (MRI scans), mammograms, positron emission tomography (PET scans), radiation treatment, ultrasounds, and X-rays.

An exhaustive list of covered procedures may be found on the Department's Fee Schedule.

Benefit Limitations

  1. Procedures for cosmetic treatment or infertility treatment (ICD-10 N97) are not covered.
  2. Procedures considered experimental or not approved by the Food and Drug Administration (FDA) are not covered.
  3. Procedures not ordered by the member's attending or treating physician are not covered.
  4. Procedures which are part of a clinical study are not covered.

Computed Tomography

  1. CT of sinuses for acute, uncomplicated rhinosinusitis (ICD-10 J01) is not covered.
  2. Cardiac CT for quantitative evaluation of coronary artery calcification (CPT 75571) is not covered.
  3. Virtual Colonoscopy (CPTs 74261, 74262, 75263) is covered at a frequency of once every five years.

Magnetic Resonance Imaging

  1. Imaging of cortical bone and calcifications, and procedures involving spatial resolution of bone and calcifications are not covered.
  2. Imaging of the same anatomic area to address patient positional changes, additional sequences, or equipment failure is not allowed. These variations or extra sequences are included within the original imaging authorization request.

Preventive Lung Cancer Low Dose Computed Tomography (LDCT) Screening

The United States Preventive Services Task Force recommends annual screening for lung cancer with low-dose computed tomography for adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.

The following policies are effective:

  1. HCPCS code G0297 must be used. G0297 always requires Prior Authorization.
  2. ICD-10 diagnosis code Z12.2 must be reported on the claim.
  3. Benefit is limited to one screening (one billed unit of service) per state fiscal year (July 1 – June 30).

Eligibility Criteria for LDCT Lung Cancer Screening

 

Member must meet all of the following criteria to be eligible for the benefit:

 

  • Between 55 and 80 years of age.
  • Asymptomatic (no signs of lung cancer).
  • History of cigarette smoking of at least 30 pack-years.
  • Current smoker or one who has quit smoking within the last 15 years.

Receives written order for LDCT lung cancer screening from a qualified physician or non-physician practitioner.

 

Coding Guidelines

  1. Regardless of billing provider type, component modifiers must be indicated on the claim if reimbursement for the procedure is split between the professional and technical components.
    1. Professional component – modifier 26
    2. Technical component – modifier TC
  2. Claims lacking a component modifier are understood to be inclusive of both components and will be reimbursed as payment in full for the entire procedure. Any separate claim for the same procedure, billed on the same date of service, will be considered an overpayment and may be subject to recovery.
  3. Outpatient Hospital claims for Imaging and Radiology must be billed via an 837I (UB-04 paper claim); Practitioner procedure claims must be billed via an 837P (CMS1500 paper claim)
  4. National Correct Coding Initiative (NCCI) billing edits affect this benefit. Providers should be familiar with the information found on the National Correct Coding Initiative in Medicaid web page on the Centers for Medicare and Medicaid Services (CMS) website, including the NCCI Policy Manual found there.
  5. All claims must include the National Provider Identification (NPI) number of the enrolled provider who rendered the service.
  6. All claims must include the NPI number of the enrolled provider who ordered the service.

Prior Authorization Requirements and Information

Health First Colorado requires all outpatient hospitals and free-standing radiology / X-ray facility centers to obtain a prior authorization (prior authorization request, PAR) for non-emergent CT, non-emergent MRI, and all PET scans. A PAR precedes the submission of a claim and must be approved in advance of the claim. Procedures which require a PAR cannot be claimed for without an approved PAR on record. Reference the Department's Fee Schedule for a list of all procedure codes which require a PAR.

All Imaging and Radiology PARs and revisions are processed by the ColoradoPAR Program and must be submitted using eQSuite ®. PARs submitted via fax or mail will not be processed. These PARs will be returned to providers via mail. This requirement only impacts PARs submitted to the ColoradoPAR Program.

To ensure claims are quickly and accurately processed, all claims for procedures which require a PAR must:

  • Contain the correct Billing Provider ID number
  • Contain procedure codes which match the corresponding PAR on record
  • Contain modifier codes which match the corresponding PAR on record

To request more information contact:
888-801-9355 or refer to the Department's ColoradoPAR Program web page.

 

PAR Revisions

If a procedure is prior authorized but the desired test was changed just prior to the time of the service, the provider is responsible for submitting a PAR revision with adequate documentation within 48 hours of the date of service for the PAR to be processed by the ColoradoPAR Program. PAR revisions can only be submitted using eQSuite®. Contact the ColoradoPAR Program at 888-801-9355 with questions regarding how to process PAR revisions.

PAR Exceptions

To request a PAR exception contact the ColoradoPAR Program at 888-801-9355 or refer to the Department's ColoradoPAR Program web page.

  1. Emergency outpatient imaging and radiology procedures are exempt from PAR requirements. To mark a claim as emergency, check the emergency indicator field.
  2. All PET and SPECT scan procedures require prior authorization regardless of whether emergency is indicated.
  3. A PAR is not required when Medicare, Medicare Advantage plans, or private insurance has made primary payment on the claim. If third party liability (TPL) carriers have not made payment on the claim, the service must be prior authorized to ensure it meets medical necessity standards of the Health First Colorado program.
  4. PARs are not required of any Imaging and Radiology procedure for the professional component if the procedure billing is split between components. The technical component still requires prior authorization.

The Department will allow retroactive authorizations when a member's eligibility is determined after the date that the service is performed. When a member's eligibility is determined after the date of service, the member is issued a Load Letter. The Load Letter must be submitted with the supporting clinical documentation for the PAR for a retroactive request to be processed by ColoradoPAR.

 

PAR Denials

If the PAR is denied, direct inquiries to the ColoradoPAR Program at 888-801-9355 or refer to the Department's ColoradoPAR Program web page.

Other PAR Policies

  • It is the provider's responsibility to maintain clinical documentation to support procedures provided in the member's file in the event of an audit or retroactive review. Submitted PARs without minimally required information or with missing or inadequate clinical information will result in a lack of information (LOI) denial.
  • All accepted PARs are reviewed by the authorizing agency. The authorizing agency approves or denies, by individual line item, each requested service or supply listed on the PAR.
  • Paper PAR forms and completion instructions are located in the Provider Services Forms section of the Department's website. They must be completed and signed by the member's physician and submitted to the authorizing agency for approval.
  • Providers should not render procedures or submit claims for procedures that require prior authorization before the PAR is approved. After the authorizing agency has reviewed the request, the PAR status is transmitted to the fiscal agent's prior approval system.
  • The status of the requested procedures is available through the Provider web portal. In addition, after a PAR has been reviewed, both the provider and the member receive a PAR response letter detailing the status of the requested procedures. Some procedures may be approved and others denied. Check the PAR response carefully as some line items may be approved and others denied.
  • Approval of a PAR does not guarantee Health First Colorado reimbursement and does not serve as a timely filing waiver. Authorization only assures that the approved service is a medical necessity and is considered a Health First Colorado covered benefit.

Billing Information

Refer to the General Provider Information manual for general billing information.

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Billing Edits

The provider’s adherence to the application of policies in this manual is monitored through either post-payment review of claims by the Department, or computer audits or edits of claims. When computer audits or edits fail to function properly, the application of policies in this manual remain in effect. Therefore, all claims shall be subject to review by the Department.

Procedure/HCPCS Codes Overview

All outpatient radiology procedures must be billed using HCPCS codes.

When submitting claims for radiology to the Health First Colorado, observe the following guidelines:

  • Always use the most current CPT revision. The Health First Colorado adds and deletes codes as they are published in annual revisions of the CPT.
  • Use CMS codes only when CPT codes are not available or are not as specific as the CMS codes.

Not all codes listed in the annual Health First Colorado HCPCS code publications are benefits of the Health First Colorado. Read the entire entry to determine the benefit status of the item.

 

The CPT Manual can be purchased at local university bookstores and from the American Medical Association at the following address:

Book & Pamphlet Fulfillment: OP 341/9
American Medical Association
P.O. Box 10946
Chicago, Illinois 60610

For more information on the Procedure/HCPCS Codes, please reference the General Provider Information manual.

 

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CMS 1500 Paper Claim Reference Table

The following paper form reference table shows required, optional, and conditional fields and detailed field completion instructions for the CMS 1500 claim form.

CMS Field Number & Label Field is? Instructions
1. Insurance Type Required Place an "X" in the box marked as Medicaid.
1a. Insured's ID Number Required Enter the member's Health First Colorado seven-digit Health First Colorado ID number as it appears on the Medicaid Identification card. Example: A123456.
2. Patient's Name Required Enter the member's last name, first name, and middle initial.
3. Patient's Date of Birth/Sex Required Enter the member's birth date using two digits for the month, two digits for the date, and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the member.
4. Insured's Name Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's full last name, first name, and middle initial. If the insured used a last name suffix (e.g., Jr, Sr), enter it after the last name and before the first name.
5. Patient's Address Not Required  
6. Patient's Relationship to Insured Conditional Complete if the member is covered by a commercial health insurance policy. Place an "X" in the box that identifies the member's relationship to the policyholder.
7. Insured's Address Not Required  
8. Reserved for NUCC Use Not Required  
9. Other Insured's Name Conditional If field 11d is marked "YES", enter the insured's last name, first name and middle initial.
9a. Other Insured's Policy or Group Number Conditional If field 11d is marked "YES", enter the policy or group number.
9b. Reserved for NUCC Use    
9c. Reserved for NUCC Use    
9d. Insurance Plan or Program Name Conditional If field 11D is marked "YES", enter the insurance plan or program name.
10a-c. Is patient's condition related to? Conditional When appropriate, place an "X" in the correct box to indicate whether one or more of the services described in field 24 are for a condition or injury that occurred on the job, as a result of an auto accident or other.
10d. Reserved for Local Use    
11. Insured's Policy, Group or FECA Number Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's policy number as it appears on the ID card. Only complete if field 4 is completed.
11a. Insured's Date of Birth, Sex Conditional Complete if the member is covered by a Medicare health insurance policy.

Enter the insured's birth date using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Place an "X" in the appropriate box to indicate the sex of the insured.
11b. Other Claim ID Not Required  
11c. Insurance Plan Name or Program Name Not Required  
11d. Is there another Health Benefit Plan? Conditional When appropriate, place an "X" in the correct box. If marked "YES", complete 9, 9a and 9d.
12. Patient's or Authorized Person's signature Required Enter "Signature on File", "SOF", or legal signature. If there is no signature on file, leave blank or enter "No Signature on File".

Enter the date the claim form was signed.
13. Insured's or Authorized Person's Signature Not Required  
14. Date of Current Illness Injury or Pregnancy Conditional Complete if information is known. Enter the date of illness, injury or pregnancy, (date of the last menstrual period) using two digits for the month, two digits for the date and two digits for the year. Example: 070114 for July 1, 2014.

Enter the applicable qualifier to identify which date is being reported.
431 - Onset of Current Symptoms or Illness
484 - Last Menstrual Period
15. Other Date Not Not Required  
16. Date Patient Unable to Work in Current Occupation Not Required  
17. Name of Referring Physician Conditional  
18. Hospitalization Dates Related to Current Service Conditional Complete for services provided in an inpatient hospital setting. Enter the date of hospital admission and the date of discharge using two (2) digits for the month, two (2) digits for the date and two (2) digits for the year. Example: 070115 for July 1, 2015. If the member is still hospitalized, the discharge date may be omitted. This information is not edited.
19. Additional Claim Information Conditional  
20. Outside Lab?
$ Charges
Not Required  
21. Diagnosis or Nature of Illness or Injury Required Enter at least one but no more than twelve diagnosis codes based on the member's diagnosis/condition.

Enter applicable ICD-10 indicator.
22. Medicaid Resubmission Code Conditional List the original reference number for resubmitted claims.

When resubmitting a claim, enter the appropriate bill frequency code in the left- hand side of the field.
7 - Replacement of prior claim
8 - Void/Cancel of prior claim
This field is not intended for use for original claim submissions.
23. Prior Authorization Conditional CLIA
When applicable, enter the word "CLIA" followed by the number.
24. Claim Line Detail Information The paper claim form allows entry of up to six detailed billing lines. Fields 24A through 24J apply to each billed line.

Do not enter more than six lines of information on the paper claim. If more than six lines of information are entered, the additional lines will not be entered for processing.

Each claim form must be fully completed (totaled).

Do not file continuation claims (e.g., Page 1 of 2).
24A. Dates of Service Required The field accommodates the entry of two dates: a "From" date of services and a "To" date of service. Enter the date of service using two digits for the month, two digits for the date and two digits for the year. Example: 010119 for January 1, 2019.
From To
01 01 19               
or
From To
01 01 19 01 01 19
Span dates of service
From To
01 01 19 01 31 19
Practitioner claims must be consecutive days.
Single Date of Service: Enter the six-digit date of service in the "From" field. Completion of the "To" field is not required. Do not spread the date entry across the two fields.

Span billing: permissible if the same service (same procedure code) is provided on consecutive dates.

Global Obstetrical care
For global obstetrical care, the "From" and "To" dates of service must be entered as the date of delivery.

Supplemental Qualifier
To enter supplemental information, begin at 24A by entering the qualifier and then the information. ZZ - Narrative description of unspecified code
N4 - National Drug Codes
VP - Vendor Product Number
OZ - Product Number
CTR - Contract Rate
JP - Universal/National Tooth Designation
JO - Dentistry Designation System for Tooth & Areas of Oral Cavity
24B. Place of Service Required Enter the Place of Service (POS) code that describes the location where services were rendered. Health First Colorado accepts the CMS place of service codes.
81 Independent Lab
24C. EMG Conditional Enter a "Y" for YES or leave blank for NO in the bottom, unshaded area of the field to indicate the service is rendered for a life-threatening condition or one that requires immediate medical intervention.

If a "Y" for YES is entered, the service on this detail line is exempt from co-payment requirements.
24D. Required Enter the HCPCS procedure code that specifically describes the service for which payment is requested.

All procedures must be identified with codes in the current edition of Physicians Current Procedural Terminology (CPT). CPT is updated annually.

HCPCS Level II Codes
The current Medicare coding publication (for Medicare crossover claims only).

Only approved codes from the current CPT or HCPCS publications will be accepted.
24D. Modifier Conditional Enter the appropriate procedure-related modifier that applies to the billed service. Up to four modifiers may be entered when using the paper claim form.

26 - Professional component
TC - Technical component
76 - Repeat procedure, same physician
77 - Repeat procedure, different physician
50 - Bilateral procedure- Both sides of the body are imaged
LT/RT - Left side/Right side- Only one (1) side was imaged
59 - Indicates that two (2) or more procedures are performed at different anatomic sites or different member encounters. Only use if no other modifier more appropriately describes the relationships of the two (2) or more procedure codes.
52 - Reduces services- Under certain circumstances, a services or procedure is reduced or eliminated at the physician’s discretion.
53 - Discontinued services- Under certain circumstances, a physician may elect to terminate a diagnostic procedure.
25 - Separate procedure during an evaluation and management visit- If a radiologist performs office visits and/or consultations and performs procedures (not 7xxxx codes) that are separately identifiable on the same date of service.
24E. Diagnosis Pointer Required Enter the diagnosis code reference letter (A-L) that relates the date of service and the procedures performed to the primary diagnosis.

At least one diagnosis code reference letter must be entered.

When multiple services are performed, the primary reference letter for each service should be listed first, other applicable services should follow.

This field allows for the entry of 4 characters in the unshaded area.
24F. $ Charges Required Enter the usual and customary charge for the service represented by the procedure code on the detail line. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.

Some CPT procedure codes are grouped with other related CPT procedure codes. When more than one procedure from the same group is billed, special multiple pricing rules apply.

The base procedure is the procedure with the highest allowable amount. The base code is used to determine the allowable amounts for additional CPT surgical procedures when more than one procedure from the same grouping is performed.

Submitted charges cannot be more than charges made to non-Health First Colorado covered individuals for the same service.

Do not deduct Health First Colorado co- payment or commercial insurance payments from the usual and customary charges.
24G. Days or Units Required Enter the number of services provided for each procedure code.
Enter whole numbers only- do not enter fractions or decimals.

Anesthesia Services
Anesthesia services must be reported as minutes. Units may only be reported for anesthesia services when the code description includes a time period.

Anesthesia time begins when the anesthetist begins member preparation for induction in the operating room or an equivalent area and ends when the anesthetist is no longer in constant attendance. No additional benefit or additional units are added for emergency conditions or the member's physical status.

The fiscal agent converts reported anesthesia time into fifteen minute units. Any fractional unit of service is rounded up to the next fifteen minute increment.

Codes that define units as inclusive numbers
Some services such as allergy testing define units by the number of services as an inclusive number, not as additional services.
24H. EPSDT/Family Plan Conditional EPSDT (shaded area)
For Early & Periodic Screening, Diagnosis, and Treatment related services, enter the response in the shaded portion of the field as follows:
AV - Available- Not Used
S2 - Under Treatment
ST - New Service Requested
NU - Not Used

Family Planning (unshaded area)
Not Required
24I. ID Qualifier Not Required  
24J. Rendering Provider ID # Required In the shaded portion of the field, enter the NPI of the Health First Colorado provider number assigned to the individual who actually performed or rendered the billed service. This number cannot be assigned to a group or clinic.
25. Federal Tax ID Number Not Required  
26. Patient's Account Number Optional Enter information that identifies the member or claim in the provider's billing system. Submitted information appears on the Remittance Advice (RA).
27. Accept Assignment? Required The accept assignment indicates that the provider agrees to accept assignment under the terms of the payer's program.
28. Total Charge Required Enter the sum of all charges listed in field 24F. Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
29. Amount Paid Conditional Enter the total amount paid by Medicare or any other commercial health insurance that has made payment on the billed services.

Do not use commas when reporting dollar amounts. Enter 00 in the cents area if the amount is a whole number.
30. Rsvd for NUCC Use    
31. Signature of Physician or Supplier Including Degrees or Credentials Required Each claim must bear the signature of the enrolled provider or the signature of a registered authorized agent.

Each claim must have the date the enrolled provider or registered authorized agent signed the claim form. Enter the date the claim was signed using two digits for the month, two digits for the date and two digits for the year. Example: 070116 for July 1, 2016.

Unacceptable signature alternatives:
Claim preparation personnel may not sign the enrolled provider's name.
Initials are not acceptable as a signature.
Typed or computer printed names are not acceptable as a signature.
"Signature on file" notation is not acceptable in place of an authorized signature.
32. Service Facility Location Information
32a- NPI Number
32b- Other ID #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.
33. Billing Provider
Info & Ph #
Required Enter the name of the individual or organization that will receive payment for the billed services in the following format:
1st Line Name
2nd Line Address
3rd Line City, State and ZIP Code
33a- NPI Number Required  
33b- Other ID #   If the Provider Type is not able to obtain an NPI, enter the eight-digit Health First Colorado provider number of the individual or organization.

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CMS 1500 Radiology Claim Example

CMS 1500 Radiology Claim Example

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Timely Filing

For more information on timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual available on the Billing Manuals web page under the General Provider Information drop-down menu.

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Outpatient Imaging and Radiology Services Revisions Log

Revision Date Addition/Changes Made by
12/1/2016 Manual revised for interChange implementation. For manual revisions prior to 12/01/2016 Please refer to Archive. HPE (now DXC)
12/27/2016 Updates Colorado iC Stage II Provider Billing Manual Comment Log v0_2.xlsx HPE (now DXC)
1/10/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx HPE (now DXC)
1/19/2017 Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx HPE (now DXC)
1/26/2017 Updates based on Department 1/20/2017 approval email HPE (now DXC)
5/22/2017 Updates based on Fiscal Agent name change from HPE to DXC DXC
6/15/2018 Reorganized some information to improve layout.
Clarified ordering/rendering provider NPI requirements.
Clarified co-pay policy.
Removed out of date LDCT lung cancer screening billing information.
Clarified clinical trial coverage.
Added specific exclusions for CT and MRI scans.
HCPF
7/9/2018 Updated co-payment to co-pay per style guide, updated timely filing info and general billing info (removed duplication from general manual & provided links) HCPF
12/21/2018 Clarification to signature requirements HCPF
3/18/2019 Clarification to signature requirements HCPF
1/15/2020 Converted to web page HCPF