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TO:  Physicians, Hospitals, Rural Health Clinics, FQHC’s and Health Departments

In order to resubmit a denied claim, the following criteria must be met: 

1.    The date of service occurred between October 1, 2014, and June 30, 2015.

2.    Provider obtained a PA for a cardiology procedure code, but during or after the procedure was performed, the procedure code required a change based on medical necessity. For example, procedure code 93303 was prior authorized but 93306 was actually performed.
The claim then denied for no PA.

3.    The new procedure code must be an authorized substitute code within the same category of the procedure code authorized on the original PA. For example, the original PA was for 93303, but 93306 was actually performed. Since 93306 is in the same category (Transthoracic Echo), the substitute code 93306 is allowed.

·         Payment will be allowed for the resubmitted cardiology claims if all the above criteria are met. Otherwise, providers should not resubmit claims for payment. 

·         If no PA was obtained prior to date of service, providers may not submit or resubmit a cardiology claim for payment.  

·         If a new, unrelated procedure code (not in the same category) was performed in lieu of the procedure authorized on the PA, payment will not be allowed. 

·         In the event a procedure was performed without obtaining a PA and subsequently a PA is requested, Medicaid’s urgent guidelines will be utilized to evaluate the request.

  Providers are required to obtain PAs for the following cardiology 
  procedure codes: