WellCare has updated its Clinical Coverage Guideline (CCG) and Claims Edit Guideline (CEG) for drug testing. Visit https://www.wellcare.com/New-York/Providers/Clinical-Guidelines to view these updated policies. Please share this notice with other members of your practice and office staff.
Beginning 9/1/2019, our clinical and coding teams will use WellCare’s Drug Testing CEG (HS-247) to ensure the extent and nature of the services rendered for a patient’s condition is justified, and WellCare will verify that submitted claims are coded correctly for drug testing in an office setting or reference laboratory. High-acuity and high frequency testing should be based on medical necessity and medical records should support services rendered. Patient drug testing should be tailored to the individual and include those drugs that are prescribed as well as common drugs of abuse. In general, when testing for drugs/drug classes, the provider must document the clinical rationale clearly in the medical records.
To ensure appropriate use of high-acuity drug testing codes upon claim submissions, WellCare providers may experience an increase in claim denials and subsequent requests for medical record submissions when submitting claims for drug testing, including HCPCS Codes G0482, G0483.
Once the requested medical records have been received and approved, WellCare will determine final payment based upon the medical record reviews.
Please feel free to contact your provider representative if you have questions or need assistance.
Thank you for working with us to provide the quality care our members – your patients – deserve.
