IHCP will mass-adjust outpatient claims that inappropriately paid for HCPCS code 81220

The Indiana Health Coverage Programs (IHCP) has identified a claim-processing issue that affects certain outpatient claims with dates of service (DOS) on or after July 1, 2015. Fee-for-service outpatient claims billed with HCPCS code 81220 – CFTR (Cystic Fibrosis Transmembrane Conductance Regulator) (eg, cystic fibrosis) gene analysis; common variants (eg, ACMG/ACOG guidelines) may have paid without the required prior authorization (PA). Affected claims would have indicated explanation of benefits (EOB) 3001 – Dates of service not on the P.A. Master File on the provider’s Remittance Advice (RA). The claim-processing issue has been resolved. Claims for the affected DOS will be mass-adjusted. Providers should begin seeing the adjusted claims on their RA statements beginning November 8, 2016, with internal control numbers (ICNs) that begin with 56 (mass adjusted). For claims that were overpaid, the net difference appears as an accounts receivable. The accounts receivable will be recouped at 100% from future claims paid to the respective provider number.