Tufts Health Public Plans Claim Edits

Transcription

1 Tufts Health Public Plans Claim Edits The following claim edits apply to contracting facilities and providers who render services for Tufts Health Public Plans products. 1 Payment methodologies are generally derived from CMS, National Correct Coding Initiative (NCCI), AMA CPT coding guidelines and Tufts Health Plan policies. Click on the following links to view claim edits by category: Allergy Testing Audiology Behavioral Health Cardiology Chiropractic Clinical Trials Dermatology Drugs and Biologicals Gastroenterology General Coding Lab/pathology Modifier OB/GYN Outpatient Surgery Topic ALLERGY TESTING Frequency of Allergy Studies Allergen Immunotherapy AUDIOLOGY Audiometric Tests Tufts Health Plan will not routinely compensate allergy studies (95004, 95017, 95018, 95024, 95027) when billed greater than 200 units within one year. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate (professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens) when billed greater than 120 units per year by any provider. Tufts Health Plan will not routinely compensate or 0212T (comprehensive audiometry threshold evaluation and speech recognition) when billed without a required diagnosis within a year of another or 0212T. Tufts Health Plan will not routinely compensate or (acoustic reflex testing) when billed within six months of another or and the diagnosis is not benign neoplasm of brain/nervous system, conversion disorder, multiple sclerosis, disease of the ear and mastoid process, poisoning by other specified antibiotics, encounter for antineoplastic chemotherapy or long term use of antibiotics. 1 Tufts Health Public Plans products include: Tufts Health Direct, Tufts Health RITogether, Tufts Health Together (includes MassHealth Plan and Accountable Care Partnership Plans), and Tufts Health Unify. Revised 08/2018 Tufts Health Public Plans Claim Edits

2 Topic Diagnosis-Procedure Consistency Physical Therapy Services Provided in an Inpatient or Outpatient Hospital Tympanometry BEHAVIORIAL HEALTH Secondary Diagnosis Codes CARDIOLOGY E/M Services with Implantable Cardiac Device Monitoring Cardiac Catheterization Cardiac Stress Tests Echocardiography Frequency Effective for dates of service on or after August 1, 2018, Tufts Health Plan will not routinely compensate for the following habilitative codes if the member is over 21 years of age on the date of service and the only diagnoses codes on the claim are unspecified or not otherwise specified (NOS): 92507, 92508, 92521, 92522, 92523, 92524, 92526, 92610, 97010, 97012, 97014, 97016, 97018, 97022, 97024, 97026, 97028, 97032, 97033, 97034, 97035, 97036, 97039, 97110, 97112, 97113, 97116, 97124, 97127, 97139, 97140, 97150, 97530, 97532, 97533, 97535, 97537, 97542, 97750, 97755, 97760, 97761, 97762, Effective for dates of service on or after August 1, 2018, Tufts Health Plan will not routinely compensate therapy services provided by a physical therapist, an occupational therapist, or a speech-language pathologist if billed with place of service 19 (outpatient hospital-off campus), 21 (inpatient hospital), or 22 (outpatient hospital-on campus). Effective for dates of service on or after August 1, 2018, Tufts Health Plan will not routinely compensate additional billings of tympanometry (92567) if billed more than twice within a year without a requisite diagnosis. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate services billed with a secondary diagnosis code as the only diagnosis on the claim. Tufts Health Plan will not routinely compensate E&M services ( or 99499) if billed without modifier 25 on the same date of service as any of the following: Implantable cardiac device monitoring services ( , , 0389T-0391T, 0417T- 0418T) Electronic analysis of antitachycardia pacemaker system (93724) Temperature gradient studies (93740) Ventricular assist device interrogation (93750) Acoustic cardiography services (0224T-0225T) Ischemia monitoring device evaluations (0305T-0306T) Tufts Health Plan will not routinely compensate cardiac catheterization when billed with a percutaneous coronary procedure and another cardiac catheterization has been billed in the previous week by any provider. Tufts Health Plan will not routinely compensate a stress test when billed within six months of another stress test when echocardiography/cardiac nuclear imaging procedure has not occurred on the same date of service, or if a coronary intervention has not occurred within that time frame (cardiac stress tests) or (stress echocardiograph testing) for a member 18 years of age or older on the date of service if the only diagnosis on the claim is for a general routine exam or screening for cardiovascular disorders. Tufts Health Plan does not routinely compensate a complete transthoracic echocardiography when the same complete echocardiography has been billed within 90 days with the same diagnosis. 2 Tufts Health Public Plans Claim Edits

3 Topic Cardiovascular Implant Device Monitoring Services Cardiac Event Detection CHIROPRACTIC Chiropractic Scope of Services CLINICAL TRIALS Billing Requirements for Clinical Trials DERMATOLOGY Actinotherapy, Phototherapy and Photochemotherapy GASTROENTEROLOGY Colonoscopy Effective for dates of service on or after April 1, 2018, Tufts Health Plan does not routinely compensate , , 93289, or (Automatic implantable cardiac defibrillator [AICD] monitoring) billed greater than once per three months when the diagnosis is Presence of automatic [implantable] cardiac defibrillator. Effective for dates of service on or after April 1, 2018, Tufts Health Plan does not routinely compensate (External mobile cardiovascular telemetry [MCT]), or (External patient activated ECG event recording) when billed more than once in a six month period by any provider. Tufts Health Plan does not routinely compensate any procedure billed by a chiropractor that is outside the scope of chiropractic practice. Tufts Health Plan does not routinely compensate any clinical trial procedure billed with modifier Q0 (investigational clinical service provided in a clinical research study that is in an approved clinical research study) or Q1 (routine clinical service provided in a clinical research study that is in an approved clinical research study) unless the required diagnosis to indicate participation in a clinical trial or research study is present on the claim. Tufts Health Plan does not routinely compensate (photochemotherapy) when billed without an appropriate diagnosis. Tufts Health Plan does not routinely compensate additional colonoscopy (45378) when billed more than once within one year. Effective for dates of service on or after July 1, 2018, Tufts Health Plan will not routinely compensate or for a patient who is less than 50 years of age on the date of service and the only diagnosis on the claim is constipation. Effective for dates of service on or after July 1, 2018, Tufts Health Plan will not routinely compensate endoscopic colorectal cancer screening (45300, 45330, 45378, 46600) for a patient who is less than 45 years of age on the date of service and the only diagnosis on the claim is screening for malignant neoplasm of colon. endoscopic colorectal cancer screenings (45300, 45330, 45378, 46600) for a member who is less than 45 years of age on the date of service if the only diagnosis on the claim is screening for malignant neoplasm of colon or for a member who is less than 50 years of age on the date of service if the only diagnosis on the claim is constipation. 3 Tufts Health Public Plans Claim Edits

4 Topic Colorectal Cancer Screening Tests - DNA Based GENERAL CODING Add-on Codes Diagnosis Specificity Manifestation Codes LABORATORY AND PATHOLOGY Fecal Occult Blood Test Gamma Glutamyltransferase Human Chorionic Gonadotropin Lipid Testing Prostate Cancer Screening Tests Prostate-Specific Antigen Prothrombin Time (PT) Screening for Cervical Cancer with Human Papillomavirus (HPV) Testing Serum Iron Studies Thyroid Testing Tumor Antigen by Immunoassay CA (oncology colorectal screening) if billed and the member's age is less than 49 years of age on the date of service. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate add-on codes if the primary procedure code has not been submitted and paid on the same date of service. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate for services if the ICD codes are not coded to the highest level of specificity. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate services billed with a manifestation code as the only diagnosis on the claim. Tufts Health Plan will not routinely compensate (blood, occult, by peroxidase activity, qualitative; feces, single specimen) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate (glutamyltransferase, gamma) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate (Gonadotropin, chorionic; quantitative) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate 80061, 82465, 83718, or (lipid testing) when billed more than six times per year in any combination by any provider. Tufts Health Plan will not routinely compensate G0102 or G0103 when billed more than once every 11 months. Tufts Health Plan will not routinely compensate (prostate specific antigen [PSA], total) when billed without a required diagnosis. Tufts Health Plan will not routinely compensate when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate HPV screening test (G0476) when billed and the patient s age is less than 30 years. Tufts Health Plan will not routinely compensate HPV screening test (G0476) when billed and the patient s age is greater than 65 years. Tufts Health Plan will not routinely compensate (Ferritin), (Iron), (Iron binding capacity) or (Transferrin) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate for (thyroxine; total), (thyroxine; free), (thyroid stimulating hormone) or (thyroid hormone uptake or thyroid hormone binding ratio) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate (immunoassay for tumor antigen, quantitative; CA 125) when billed without a covered diagnosis. 4 Tufts Health Public Plans Claim Edits

5 Topic Tumor Antigen by Immunoassay CA 15-3/CA Tumor Antigen by Immunoassay CA 19-9 Urine Culture, Bacterial Vitamin D Testing Duplicate Claim Lines for Independent Laboratory Services Human Papilloma Virus (HPV) Testing Travel Allowance for Specimen Collection from Homebound or Nursing Home Bound Patient Colorectal Cancer Screening Tests - DNA Based Frequency Limitations for Drug Testing Tufts Health Plan will not routinely compensate (immunoassay for tumor antigen, quantitative; CA 15-3 [27.29]) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate (immunoassay for tumor antigen, quantitative; CA 19-9) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate bacterial urine cultures (87086, 87088) when billed without a covered diagnosis. Tufts Health Plan will not routinely compensate (vitamin D; 25 hydroxy) when billed more than once per year and the diagnosis is not vitamin D deficiency. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate duplicate claim lines reported by an independent laboratory when billed by a different Tax ID, any provider ID or any specialty. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate HPV testing ( , G0476) for a female patient less than age 30 when the only diagnosis is a screening diagnosis code. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate for (Infectious agent detection by nucleic acid [DNA or RNA]; Human Papillomavirus [HPV] low-risk types) when billed. HPV testing ( , 0500T, G0476) if billed more than once in a five-year period by any provider for a female member between 30 and 65 years of age on the date of service if the only diagnosis is a screening diagnosis code. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate P9603 or P9604 (travel allowance one way in connection with medically necessary laboratory specimen) when billed without a specimen collection code ( , , 51701, G0471, P9612, P9615). Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate (oncology colorectal screening) when billed without a colorectal cancer screening diagnosis. Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate (oncology colorectal screening) when billed and the patient's age is greater than 85 years. Effective for dates of service on or after April 1, 2018, Tufts Health Public Plan will not routinely compensate for drug test(s) presumptive ( ) and drug(s) or substance(s), definitive, qualitative or quantitative ( ) when billed with any combination of more than 20 units within 365 days per member, as it exceeds clinical guidelines. This edit applies to Tufts Health Direct only. Effective for dates of service on or after April 1, 2018, Tufts Health Public Plan will not routinely compensate for drug test(s), definitive (G0480-G0483, G0659) when billed more than 10 units within 365 days per member, as it exceeds clinical guidelines. This edit applies to Tufts Health Direct only. 5 Tufts Health Public Plans Claim Edits

6 Topic Urine Validity and Drug Testing Colorectal Cancer Screening Cologuard Endometrial Biopsy for Infertility Genital Herpes Screening MODIFIER Consistency of Reduced or Discontinued Services Between Professional and Facility Providers Discontinued Service Modifier in the Outpatient Setting Distinct Service Modifiers Repeat Procedure by the Same or Another Physician OBSTETRICS/GYNECOLOGY Cervical Cancer Screening Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate for urinalysis ( , 81005, 81099), creatinine (82570), ph; body fluid (83986), or spectrophotometry (84311) when billed with the following toxicology procedure codes: Presumptive drug screen ( , G0477-G0479) Definitive drug testing ( , 83992, G0480-G0483). Effective for dates of service on or after July 1, 2018, Tufts Health Plan will not routinely compensate 82270, G0104, G0106, or G0328 (colorectal cancer screening) when billed and the patient is less than 45 years of age on the date of service. Effective for dates of service on or after July 1, 2018, Tufts Health Plan will not routinely compensate (Oncology colorectal screening) when billed and the patient's age is less than 50 years of age on the date of service or (endometrial biopsy) if the only diagnosis on the claim is infertility or infertility encounter (antibody; herpes simplex, type 2) if billed for a member 13 years of age or older on the date of service if the only diagnosis is a screening diagnosis code. a service reported by a professional provider when billed without modifiers 52 or 53 if the same code is billed for the same date of service by an outpatient facility with modifiers 73 or 74. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate any service billed with modifier 53 (discontinued service) when billed with places of service 19 (outpatient hospital-off campus), 22 (outpatient hospital-on campus) or 24 (ambulatory surgical center). Tufts Health Plan will not routinely compensate inappropriately billed distinct service modifiers billed with anesthesia codes ( , or D9223). Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate services that are inappropriately billed with distinct service modifiers. For example, modifier 25 is only appropriate on Evaluation and Management procedures. Tufts Health Plan will not routinely compensate procedures appended with modifier 76 (repeat procedure/same physician) when the same procedure code has not been billed by the same Provider ID on the same date of service, or within the post-operative period of the billed procedure. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate for cervical or vaginal screening services for a female patient less than 21 years of age when the only diagnosis is a screening diagnosis code. 6 Tufts Health Public Plans Claim Edits

7 Topic Cervical Cancer Screening Cervical Cancer Screening Screening Pelvic Examinations Global Obstetrical Package OUTPATIENT AAOS Intraoperative Services Arthrocentesis Cystourethroscopy Electrical Stimulation (ES) and Electromagnetic Therapy for the Treatment of Wounds Electroencephalogram (EEG) Erectile Dysfunction cervical or vaginal screening services for a female member 21 years of age or older when the only diagnosis is a screening diagnosis code and any of these screening services has been reported in the previous 13 months. cervical or vaginal screening services for a female member 21 years of age or older on the date of service if the only diagnosis is a screening diagnosis code and any of these screening services has been reported in the previous three years. Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate screening pelvic examination (G0101) when billed by any provider more than once within two years from the first date of service, except when a high risk diagnosis is present. Effective for dates of service on or after August 1, 2018, Tufts Health Plan will not separately compensate E&M services that are included in the global obstetrical package for uncomplicated maternity cases billed on the same day as the delivery. Effective for dates of service on or after August 1, 2018, Tufts Health Plan will not routinely compensate E&M services or postpartum care billed within 42 days (6 weeks) by the same Tax ID and specialty that performed a delivery that includes postpartum care. Tufts Health Plan will not routinely compensate intraoperative services when billed with an orthopedic procedure. Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate or (arthrocentesis, aspiration and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]) when submitted without an appropriate diagnosis code, as defined by CMS guidelines. Tufts Health Plan will not routinely compensate or (cystourethroscopy with lithotripsy) when another cystourethroscopy with lithotripsy for the same side has been billed in the previous month. Tufts Health Plan will limit coverage of G0281 (electrical stimulation, unattended, for chronic ulcers) or G0329 (electromagnetic therapy, for chronic ulcers) to appropriate ulcer diagnoses. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate 95950, 95951, 95953, (24-Hour EEG monitoring) or (EEG for epileptic spike analysis) when billed in any combination greater than three days. Effective for dates of service on or after January 1, 2018, Tufts Health Plan will not routinely compensate (EEG for epileptic spike analysis) when billed on same date of service as 95951, 95953, or (monitoring for localization of cerebral seizure focus). Tufts Health Plan will not routinely compensate inject corpora cavernosa with pharmacologic agents (54235) if billed more than one unique date of service within a year by any provider. 7 Tufts Health Public Plans Claim Edits

8 Topic Home PT/INR Monitoring for Anticoagulation Management Intravenous and Venous Services Lung Cancer Screening with Low Dose Computed Tomography (LDCT) Nasal Endoscopy Needle EMG Nerve Conduction Studies (NCS) and Electromyography (EMG) for Radiculopathy Procedures of the Knee Psychological or Neuropsychological Testing Tufts Health Plan does not routinely compensate G0248-G0250 (home prothrombin time [INR] monitoring) when billed without a covered diagnosis. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate additional units of G0249 if more than three units have been billed within a three-month period. Tufts Health Plan does not routinely compensate (injection of sclerosing solution; single vein; multiple veins, same leg) when billed in any combination greater than 4 unique visits within a three-month time frame by any provider. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate G0296 (counseling visit to discuss need for lung cancer screening), or G0297 (low-dose CT scan [LDCT] for lung cancer screening) when billed and the diagnosis is not personal history of tobacco use/personal history or nicotine dependence, cigarettes. Tufts Health Plan does not routinely compensate nasal endoscopy with debridement (31237) when it has been billed more than three times in the 3-month period following a surgical sinus endoscopy ( , 0406T-0407T). Tufts Health Plan does not routinely compensate needle EMG; 1-4 extremities with or without related paraspinal areas when billed and the only diagnosis code is carpal tunnel syndrome. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate needle electromyography ( ) when billed without a nerve conduction study (95905) and the only diagnosis on the claim is radiculopathy. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate nerve conduction study ( ) when billed without a needle electromyography (95885, 95886) and the only diagnosis on the claim is radiculopathy. Tufts Health Plan does not routinely compensate (arthroscopy of knee with abrasion arthroplasty) when billed with (arthroscopy of knee with meniscectomy). Tufts Health Plan does not routinely compensate additional units of 96101, 96102, 96116, 96118, or when billed more than eight units in any combination. Surgical Dressings Tufts Health Plan does not routinely compensate surgical dressings billed in the provider's office (POS 11). Suture Removal Therapy Services Modifiers GN, GO and GP Trigger Point Injections Tympanometry Tufts Health Plan does not routinely compensate or (removal of sutures under anesthesia [other than local]) when the patient's age 21 and older. Tufts Health Plan does not routinely compensate non-therapy services when billed with therapy services modifiers GN, GO or GP. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate any combination of trigger point injections (20552, 20553) when billed more than three times in a 90-day period day period at the same anatomic site. Tufts Health Plan does not routinely compensate additional billings of tympanometry (92567), when billed more than twice within a year without the appropriate diagnosis. 8 Tufts Health Public Plans Claim Edits

9 Topic Ulcer Debridement and Ulcer Stages Urinary Catheter for Incontinence Urodynamics Vagus Nerve Stimulation (VNS) SURGERY Implantable Neurostimulator Electrode Effective for dates of service on or after April 1, 2018, Tufts Health Plan does not routinely compensate (debridement) when billed with a pressure ulcer stage 1 or stage 2 diagnosis and another pressure ulcer stage (3 or 4) or a non-pressure chronic ulcer diagnosis is not reported on the claim. catheter insertion (51702, 51703) if the only diagnosis on the claim is urinary incontinence. Tufts Health Plan does not routinely compensate (measurement of post-voiding residual urine) or (pelvic ultrasound) when billed on the same date of service as (simple or complex cystometrogram). Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate neurostimulator procedure (insertion, replacement, revision, removal or analysis) when billed with a diagnosis of depressive disorders. Effective for dates of service on or after January 1, 2018, Tufts Health Plan does not routinely compensate L8680 (Implantable neurostimulator electrode, each) when billed with (Percutaneous implantation of neurostimulator electrode array, epidural). Drugs and Biologicals Drug Abatacept (Orencia ) Tufts Health Plan will not compensate abatacept (J0129) when billed with a nonchemotherapy or chemotherapy IV administration code (96365, 96367, 96368, 96413, 96417) and J0129 has been billed in the previous 12 days. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0129 to the following when billed by any provider: 100 combined units per date of service if the diagnosis is juvenile idiopathic arthritis, psoriatic arthritis, or rheumatoid arthritis 13 combined units per date of service by any provider if billed with subcutaneous administration codes (96372, 96377) and no other drug administered by non-chemotherapy subcutaneous technique has been billed for the same date of service J0129 when billed by any provider in the following circumstances: More than one unique visit per week if the diagnosis is juvenile idiopathic arthritis, psoriatic arthritis, or rheumatoid arthritis, except when the IV loading dose of J0129 is administered the previous day (non-chemotherapy IV administration) if billed with J0129 and no other drug administered by non-chemotherapy IV push technique has been billed for the same date of service. 9 Tufts Health Public Plans Claim Edits

10 Ado-trastuzumab emstansine (Kadcyla ) Aflibercept (Eylea ) Agalsidase beta (Fabrazyme ) Alemtuzumab Alglucosidase alfa (Myozyme, Lumizyme ) Autologous cultured chondrocytes, implant BCG (Intravesical) Bendamustine HCI (TREANDA ) Tufts Health Plan will not compensate J9354 if billed without a diagnosis of breast cancer. Note: This applies to Tufts Health Together only. Tufts Health Plan limits coverage of J9354 to the following: 411 combined units per date of service Once every 19 days Tufts Health Plan does not routinely compensate for J0178 if billed more than two visits per 28 days. J0180 if billed and the member is less than eight years of age on the date of service. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0202 to 12 combined units per date of service by any provider. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0220 or J0221 to 228 combined units per date of service by any provider. Tufts Health Plan does not compensate (autologous chondrocyte implantation, knee) if billed and autologous cultured chondrocytes (J7330) has not been billed for the same date of service. Effective for dates of service on or after April 1, 2018, Tufts Health Plan does not routinely compensate for J7330 unless has also been billed for the same date of service. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9031 to 1 unit per date of service or 1 visit per week if the diagnosis is urothelial carcinoma. J9031 unless or (bladder installation administration) has also been billed for the same date of service. Tufts Health Plan limits coverage of J9033 to 296 combined units per date of service when the diagnosis is any of the following: Adult T-cell leukemia/lymphoma AIDS-related B-cell lymphoma Hodgkin's lymphoma Non-Hodgkin's lymphoma Tufts Health Plan limits coverage of J9033 to 2,952 combined units in a 24-week period when the diagnosis is chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit coverage of J9033 to 1,326 combined units within a 12-week period by any provider if the diagnosis is Waldenstrom's macroglobulinemia or lymphoplasmacytic lymphoma. 10 Tufts Health Public Plans Claim Edits

11 Bortezomib (Velcade ) Botulinum Toxin A (Botox ) Certolizumab pegol (Cimzia ) Cetuximab (Erbitux ) Collagenase clostridium histolyticum (Xiaflex ) Corticotropin Daratumumab (Darzalex ) Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9033 to 2,336 combined units within a 12-week period by any provider if the diagnosis is any of the following: Adult T-cell leukemia/lymphoma AIDS-related B-cell lymphoma Breast cancer Hodgkin's lymphoma (classical) Mantle cell lymphoma Non-Hodgkin's lymphoma (except mantle cell lymphoma) J9041 if billed by any provider more than twice per week. Tufts Health Plan limits coverage of J0585 to the following: 80 combined units per date of service when the diagnosis is tardive dyskinesia 150 combined units per date of service when the diagnosis is axillary hyperhidrosis Note: This applies to Tufts Health Unify only. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0585 to 20 combined units per date of service if the diagnosis is oculomotor injury (acute) or vocal cord granuloma. Tufts Health Plan limits coverage of J0717 to 400 combined units per date of service. Note: This applies to Tufts Health Unify only or (chemotherapy IV administration) if billed with J9055 and no other drug administered by chemotherapy administration has been billed for the same date of service. J0775 if billed under the following circumstances: If billed with a diagnosis of Peyronie's disease and (administration) has not been billed for the same date of service If billed with a diagnosis of Peyronie's disease and (corpora cavernosa injection) has not been billed for the same date of service or in the previous three days If billed without (injection, enzyme, palmar fascial cord) and the diagnosis is Dupuytren's contracture If (manipulation, palmar fascial cord, post enzyme injection, single cord) is billed with a diagnosis of Dupuytren's contracture, and or J0775 has not been billed for the same date of service or in the previous three days. IV infusion ( , ) if billed with J0800 and no other drug administered by nonchemotherapy IV administration has been billed for the same date of service by any provider. J9146 under any of the following circumstances: If billed more than once per week with a diagnosis of multiple myeloma If billed with modifier JW and the units equal or exceed Tufts Health Public Plans Claim Edits

12 Darbepoetin alfa (Aranesp ) Decitabine Denosumab (Prolia, Xgeva ) Dexamethasone, intravitreal implant (Ozurdex ) Docetaxel (Taxotere ) Tufts Health Plan will not routinely compensate for J0881 if billed without the following diagnoses combinations: Nonmyeloid malignant neoplasm and anemia Hepatitis C treatment with ribavirin and anemia of other chronic disease Tufts Health Plan limits coverage of coverage of J0882 to 52 combined units when J0882 has not been billed in the previous 28 days or Q4081 (Epoetin alfa, 100 units for ESRD use) has not been billed in the previous two weeks by any provider. for J0881 or J0882 if any of the following have not been billed on the same day or within the last 7 days by any provider: (general health panel) (obstetrical panel) (CBC, automated with WBC) (CBC, automated) (hematocrit, spun) (hematocrit) (hemoglobin) G0306 (CBC, automated with WBC) G0307 (CBC, automated) Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0894 to 49 units per date of service if billed with a diagnosis of myelofibrosis. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0897 to 120 combined units per date of service if the diagnosis is bone metastases, giant cell tumor of bone, hypercalcemia of malignancy or multiple myeloma. Tufts Health Plan does not routinely compensate dexamethasone (J7312) if a diagnosis for diabetic macular edema, macular edema following branch or central retinal vein occlusion, or non-infectious uveitis affecting the posterior segment is not present on the claim. Tufts Health Plan limits coverage of dexamethasone (J7312) to 14 combined units per date of service. Tufts Health Plan does not compensate dexamethasone (J7312) if billed without intravitreal injection of a pharmacologic agent (67028). Tufts Health Plan will not compensate (Intravitreal injection of a pharmacologic agent [separate procedure]) when billed with dexamethasone (J7312) and modifier LT (Left side), RT (Right side), or 50 (Bilateral procedure) is not appended to code Tufts Health Plan will limit coverage of docetaxel (J9171) to 185 units per date of service and the diagnosis is esophageal cancer, Ewing's sarcoma, occult primary, or osteosarcoma Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9171 to 147 units per date of service if billed with a diagnosis of thyroid carcinoma. 12 Tufts Health Public Plans Claim Edits

13 Doxorubicin HCL Liposome (Doxil, Lipo-Dox ) Ecallantide (Kalbitor) Eculizumab (Soliris ) Tufts Health Plan will not routinely compensate for , , 96542, Q0083 when billed with doxorubicin HCL liposome (Q2049-Q2050) and when another drug administered by chemotherapy administration has not been billed for the same date of service. Q2049 or Q2050 if billed with a diagnosis of Kaposi's sarcoma unless a diagnosis of human immunodeficiency virus (HIV) disease is present. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit Q2049 or Q2050 to the following: 5 units per date of service if the diagnosis is AIDS-related Kaposi's sarcoma or Castleman's disease 13 units per date of service if billed with a diagnosis of breast cancer, dermatofibrosarcoma protuberans, endometrial carcinoma, ovarian cancer/primary peritoneal cancer, soft tissue sarcoma or uterine sarcoma Tufts Health Plan will not compensate Ecallantide (J1290) when billed and a diagnosis of hereditary angioedema is not present on the claim. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J1300 to 90 combined units per date of service or 600 combined units in 10 weeks if a diagnosis of paroxysmal nocturnal hemoglobinuria is billed. Tufts Health Plan will not routinely compensate for epoetin alfa HCl (Q4081) when billed and an FDA approved indication or an approved off-labeled indication is not present on the claim. Epoetin Alfa (Procrit, Epogen Tufts Health Plan will limit coverage of epoetin alfa (J0885) to 60 combined units per date of service when the diagnosis on the claim is End Stage Renal Disease, chronic kidney disease, non-myeloid malignancy, or personal history of antineoplastic chemotherapy, and the patient is greater than 17 years of age, and epoetin alfa (J0885, or Q4081) has been billed in the previous week by any provider. J0885 if billed with a diagnosis of anemia due to neoplastic disease or anemia in members receiving immunosuppressive chemotherapy with at least two additional months of planned chemotherapy, unless a laboratory service that includes hemoglobin testing has been billed for the same date of service or in the previous two weeks by any provider. J0885 if billed with a diagnosis of anemia in members with chronic kidney disease not on dialysis unless an iron status study (82728, 83540, 83550) has been billed on the same date of service or within the previous 12 weeks Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J0885 to the following when billed by any provider: 12 combined units per date of service if the diagnosis is anemia in patients with chronic kidney disease not on dialysis and the member is 17 years of age or older on the date of service, and J0885 has not been billed in the previous week 6 combined units per date of service if the diagnosis is anemia in members with congestive heart failure 13 Tufts Health Public Plans Claim Edits

14 Erythropoiesis Stimulating Agents (ESAs) in Cancer and Related Neoplastic Conditions Eribulin mesylate (Halaven ) Ferumoxytol (Feraheme ) Fluocinolone acetonide, intravitreal implant (Retisert ) Gemcitabine HCl (Gemzar ) Goserelin Acetate Implant (Zoladex ) Hydroxyprogesterone caproate (Makena ) subcutaneous or intramuscular injection (96372) if billed with J0885 and all of the following are met: The diagnosis is anemia in members receiving myelosuppressive chemotherapy with at least two additional months of planned chemotherapy The member is less than 18 years of age No other nonchemotherapy subcutaneous or intramuscular drug has been billed for the same date of service Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate J0881, J0885 or J0888 for non-end-stage renal disease (ESRD) ESA treatments when billed with modifier EB. Effective for dates of service on or after April 1, 2018, Tufts Health Plan will not routinely compensate J0881, J0885 or J0888 when billed with modifier EC and the diagnosis associated to the claim line is not approved for ESA treatment. Tufts Health Plan will not routinely compensate , ,96542, (Chemotherapy administration by other than intravenous push technique code), when billed with eribulin mesylate (J9179) and no other drug administered via chemotherapy administration is billed for the same date of service by any provider. Q0139 if billed with a diagnosis of anemia in chronic kidney disease and a diagnosis of ESRD is not present. Tufts Health Plan will not compensate Fluocinolone acetonide (J7311) if billed without a diagnosis of chronic noninfectious uveitis affecting the posterior segment. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9201 to the following: 27 units per date of service 13 units per date of service by any provider if the diagnosis is Ewing's sarcoma, mantle cell lymphoma, occult primary, osteosarcoma, thymoma and thymic carcinoma, or urothelial carcinoma of the prostate 16 units per date of service if the diagnosis is AIDS-related B-cell lymphoma, cervical cancer, head and neck cancer, kidney cancer, non-hodgkin's lymphoma (excluding cutaneous T-cell lymphoma and mantle cell lymphoma), non-small cell lung cancer, small cell lung cancer, or uterine sarcoma. J9202 if billed more than once within a month. Tufts Health Plan will limit coverage of hydroxyprogesterone caproate (J1725) to the following: 250 combined units per date of service when the diagnosis is pregnancy with history of singleton spontaneous preterm birth or test for endogenous estrogen production One unique visit per week if the diagnosis is singleton pregnancy with history of singleton spontaneous preterm birth One visit per 6 days 14 Tufts Health Public Plans Claim Edits

15 Infliximab (Remicade ) Ipilimumab (Yervoy ) Irinotecan (Camptosar ) Tufts Health Plan limits J1745 or Q5102 to 342 combined units within a 26-week period if: The diagnosis is acute graft-versus-host disease following peripheral blood stem cell transplant, adult ankylosing spondylitis, adult-onset Still's disease, SAPHO syndrome, or sarcoidosis The member is less than 18 years of age on the date of service, and the diagnosis is pediatric regional enteritis (Crohn's disease) or pediatric ulcerative colitis The member is greater than 18 years of age on the date of service and the diagnosis is adult regional enteritis (Crohn's disease) or adult ulcerative colitis J9228 if billed more than seven times per year when the diagnosis is central nervous system metastases (melanoma), melanoma, or small cell lung cancer. Tufts Health Plan will limit coverage of Irinotecan (J9206) to three combined units per date of service by any provider when the diagnosis is Ewing's sarcoma. J9206 if billed and the member is less than 18 years of age on the date of service and the diagnosis is any of the following: Acute lymphoblastic leukemia Acute myeloid leukemia Anaplastic glioma Breast cancer Cervical cancer Colorectal cancer Esophageal cancer Esophagogastric junction cancer Gastric cancer Glioblastoma multiforme Non-Hodgkin's lymphoma Non-small cell lung cancer Occult primary Ovarian cancer Pancreatic adenocarcinoma Small cell lung cancer Vaginal cancer J9205 if billed by any provider more than once every two weeks with a diagnosis of pancreatic adenocarcinoma. 15 Tufts Health Public Plans Claim Edits

16 Iron dextran (INFed ) Iron sucrose (Venofer ) Ixabepilone (Ixempra ) Lanreotide (Somatuline Depot ) Leuprolide acetate depot, 3.75 mg (Lupron Depot, Eligard ) Leuprolide Acetate Depot, 7.5 mg (Lupron Depot, Eligard ) J9206 if billed and one of the following laboratory services has not been billed for the same date of service or in the previous 7 days by any provider: (general health panel) 80055, (obstetrical panel) (differential WBC count) (manual differential WBC count, buffy coat) (complete CBC) (manual cell count) G0306-G0307 (complete CBC) J1750 if billed with a diagnosis of anemia complicating pregnancy and a diagnosis of iron deficiency anemia is not also present. J1750 if billed with a diagnosis of encounter for antineoplastic chemotherapy and a diagnosis of nonmyeloid malignancy is not also present. Tufts Health Plan will limit coverage of iron sucrose (J1756) to 500 combined units per date of service when billed by any provider. J1756 if billed with a diagnosis of ESRD unless a diagnosis of dialysis status is also present. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J1756 to 300 combined units per date of service when the diagnosis is cancer-induced anemia or chemotherapy-induced anemia. Tufts Health Plan will not routinely compensate (Chemotherapy administration, IV infusion technique, first hour) when billed with ixabepilone (J9307) and (Chemotherapy administration, IV infusion technique, each additional hour) has not been billed for the same date of service. Tufts Health Plan will not routinely compensate for lanreotide (J1930) if an approved indication or approved off-label indication is not also billed. Note: This does not apply to Tufts Health Together. Tufts Health Plan will not routinely compensate for lanreotide (J1930) when billed by any provider more than once every 26 days and the diagnosis is acromegaly or gastroenteropancreatic neuroendocrine tumors. Tufts Health Plan will not routinely compensate for leuprolide acetate (J1950) when billed by any provider more than once per month. Tufts Health Plan will not routinely compensate for leuprolide acetate (J1950) when billed and the patient's age is less than 18 years and the diagnosis is other than central precocious puberty. Note: This does not apply to Tufts Health Together. Tufts Health Plan will not routinely compensate for leuprolide acetate (J9217) when billed and the patient is less than 18 years of age and the diagnosis is other than central precocious puberty. Note: This does not apply to Tufts Health Together. 16 Tufts Health Public Plans Claim Edits

17 Leuprolide acetate, 1 mg (Lupron ) Nivolumab (OPDIVO ) Ocriplasmin (Jetrea ) Octreotide Acetate Depot (Sandostatin LAR ) Ofatumumab (ARZERRA ) Olaratumab Omalizumab (Xolair ) Tufts Health Plan will not routinely compensate for Leuprolide acetate (J9218) when billed and the patient's age is less than 18 years and the diagnosis is other than central precocious puberty. Note: This does not apply to Tufts Health Together. Tufts Health Plan will not routinely compensate for nivolumab (J9299) when billed and an FDA-approved indication is not present on the claim. Tufts Health Plan will not routinely compensate for nivolumab (J9299) when billed with a diagnosis of unresectable or metastatic malignant melanoma, and BRAF V600 mutation testing has not been previously billed by any provider in the patient's lifetime. Tufts Health Plan will limit coverage of nivolumab (J9299) to 342 combined units per date of service by any provider and the diagnosis is Hodgkin's lymphoma (classical). Tufts Health Plan will not routinely compensate for nivolumab (J9299) when billed by any provider more than one visit every 12 days and the diagnosis is Hodgkin's lymphoma [classical], kidney cancer, melanoma and non-small cell lung cancer Tufts Health Plan will not routinely compensate for nivolumab (J9299) when billed with modifier JW and the units equal or exceed 40. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9299 to 114 combined units per date of service if billed with J9228 and the diagnosis is melanoma. J9299 if billed with a diagnosis of microsatellite instability-high (MSI-H) or mismatch repair deficient (dmmr) cancer, unless 81301, 81479, 88341, 88342, or 0037U (MSI-H or dmmr testing) or J9299 has not been previously billed by any provider in the member s lifetime. Tufts Health Plan will not compensate Ocriplasmin(J7316) when billed and an FDA- approved indication is not present on the claim. Tufts Health Plan will limit coverage of octreotide acetate depot (J2353) to 40 combined units per date of service when billed by any provider. Tufts Health Plan will not routinely compensate for octreotide acetate depot (J2353) when billed more than one visit every 12 days by any provider. Tufts Health Plan will not routinely compensate ofatumumab (J9302) when billed by any provider more than 15 unique visits in two years and the diagnosis on the claim is chronic lymphocytic leukemia/small cell lymphoma [CLL/SLL]. J9285 if billed more than 2 visits every 3 weeks and the diagnosis is soft tissue sarcoma. Tufts Health Plan will limit coverage of omalizumab (J2357,) to 150 combined units per date of service by any provider when the diagnosis is latex allergy. Tufts Health Plan will not compensate drug administration services (Other than for subcutaneous technique) when billed with omalizumab (J2357) and no other drug has been billed for the same date of service by any provider. 17 Tufts Health Public Plans Claim Edits

18 Oxaliplatin (Eloxatin ) Paclitaxel protein-bound particles (Abraxane ) Panitumumab Pegfilgrastim (Neulasta ) Pegloticase (Krystexxa ) Pembrolizumab (Keytruda ) Tufts Health Plan does not routinely compensate oxaliplatin (J9263) if billed more than once every 12 days and the diagnosis on the claim is colorectal cancer, esophageal cancer, head and neck cancer, non-hodgkin's lymphoma, occult primary, pancreatic cancer or small intestine cancer. J9264 if billed more than the following: Once within a week with a diagnosis of breast cancer, hypersensitivity to docetaxel or paclitaxel, melanoma, non-small cell lung cancer, ovarian cancer, or pancreatic adenocarcinoma Once within three weeks and the diagnosis is endometrial carcinoma, head and neck cancer, or urothelial carcinoma J9264 if billed with a diagnosis of pancreatic adenocarcinoma unless J9201 (gemcitabine HCL) has been billed for the same date of service. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9303 to the following when billed: 69 combined units per date of service One unit of (IV chemotherapy administration) if billed with J9303 and no other drug administered by IV chemotherapy administration has been billed for the same date of service Tufts Health Plan does not routinely compensate for pegfilgrastim (J2505) when billed more than once every 12 days and the diagnosis is chemotherapy-induced neutropenia, mobilization of peripheral blood progenitor cells prior to autologous stem cell transplantation, or post-peripheral blood progenitor cell transplant supportive care. Note: This does not apply to Tufts Health Direct. J2505 when billed and the patient is less than 18 years of age and the diagnosis is mobilization of peripheral blood progenitor cells prior to autologous stem cell transplantation, or post-peripheral blood peripheral blood progenitor cell transplant supportive care. Tufts Health Plan does not compensate pegloticase (J2507) if billed without a diagnosis of chronic gout in adult patients refractory to conventional treatment. Note: This applies to Tufts Health Unify only. Tufts Health Plan does not compensate pembrolizumab (J9271) if billed more than once every 19 days and the diagnosis is head and neck carcinoma, melanoma, merkel cell carcinoma or non-small cell lung cancer. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9271 to 200 combined units per date of service when the diagnosis is esophagogastric junction cancer, gastric cancer, head and neck cancer, Hodgkin's lymphoma (classical), melanoma, microsatellite instability-high cancer, non-small cell lung cancer, or urothelial carcinoma. 18 Tufts Health Public Plans Claim Edits

19 Pemetrexed (Alimta ) Pertuzumab (Perjeta ) Ramucirumab Regadenoson (Lexiscan TM ) Rituximab (Rituxan ) Romiplostim (Nplate ) J9271 if: Billed with modifier JW and the units equal or exceed 50 Billed with a diagnosis of MSI-H or dmmr cancer, and MSI-H or dmmr testing (81301, 81479, 88341, 88342, or 0037U), or J9271 has not been previously billed by any provider in the member s lifetime Tufts Health Plan limits coverage of pemetrexed (J9305) to 123 combined units per date of service by any provider when the diagnosis on the claim is gastric cancer, mesothelioma, non-small cell lung cancer, or thymoma and thymic malignancy or (IV chemotherapy administration) if billed with J9305 in any combination with more than one unit and no other drug administered by IV chemotherapy push has been billed for the same date of service. Tufts Health Plan does not compensate Pertuzumab (J9306) if billed without a diagnosis of breast cancer, or if trastuzumab (J9355) has not been billed for the same date of service. Note: This applies to Tufts Health Together only or (IV chemotherapy administration) if billed with J9306 and no other drug administered by IV chemotherapy administration has been billed for the same date of service by any provider. Effective for dates of service on or after October 1, 2018, Tufts Health Plan will limit J9308 to once every two weeks and/or 182 combined units per date of service by any provider if billed with a diagnosis of colorectal cancer, esophageal cancer, esophagogastric junction cancer or gastric cancer. J2785 if billed and a myocardial stress test has not been billed on the same date of service. Tufts Health Plan limits coverage of rituximab (J9310) to 10 combined units per date of service by any provider when A9542 (Indium In-111 ibritumomab tiuxetan, diagnostic) or A9543 (Yttrium Y-90 ibritumomab tiuxetan, therapeutic) has not been billed for the same date of service, and the diagnosis is not chronic lymphocytic leukemia, minimal change disease, or systemic lupus erythematosus. Tufts Health Plan does not compensate rituximab (J9310) if billed more than once every four days and the diagnosis is Evans syndrome or Waldenström macroglobulinemia. Tufts Health Plan does not compensate rituximab (J9310) when billed by any provider more than 12 times in a patient's lifetime and the diagnosis is chronic lymphocytic leukemia, hairy cell leukemia, large B-cell lymphoma, or mantle cell lymphoma. J2796 if billed more than once a week and the diagnosis is chronic immune thrombocytopenia (ITP). nonchemotherapy drug administration services (other than for subcutaneous technique) if billed with J2796 and no other drug administered by other than subcutaneous technique has been billed for the same date of service. 19 Tufts Health Public Plans Claim Edits