andersona1229
Contributor
I know this is a rather specific question so even if you have any input that would be fantastic. I've been going back and forth for the last 5-6 years with MCOs in Utah about the substance use disorder (SUD) carve out for UDT. The only place the carve-out is mentioned is in a MIB from April 2018 announcing the policy; it doesn't appear in any of their other manuals. It states that if a claim has the diagnosis codes F10.00-F19.99 as first listed/primary diagnosis with any of the presumptive & definitive drug testing CPTs it is payable by state Medicaid. All other diagnosis codes are still payable by the MCOs.
It took me a good 2-3 years to get Select Health onboard with understanding that they have to pay even if it is a non-SUD F code (think F90.9) on the claim. Right after I get that taken care of, Molina starts denying all UDT saying that all UDT is carved out to the state. They even went back and recouped about a years worth of claims for it. I've appealed multiple times including a denied UT Medicaid EOB saying that they're responsible and a copy of the bulletin explaining the policy. Each of those appeals has been denied. They recently started trying to cite a policy in the "2022 Utah Medicaid Provider Manual" saying that everything is carved out to the state. There is nothing it the manual regarding any carve-outs for UDT. I have no idea what they're talking about.
I'm in the process of appealing another claim and then escalating it as high as I can. I had to stop working on the original appeals process because of the disastrous NCCI edit situation. I wanted to check and see if anybody else has seen this before or has any suggestions. I think I've done everything right here but maybe I'm missing something? I don't know.
Thanks yall.
It took me a good 2-3 years to get Select Health onboard with understanding that they have to pay even if it is a non-SUD F code (think F90.9) on the claim. Right after I get that taken care of, Molina starts denying all UDT saying that all UDT is carved out to the state. They even went back and recouped about a years worth of claims for it. I've appealed multiple times including a denied UT Medicaid EOB saying that they're responsible and a copy of the bulletin explaining the policy. Each of those appeals has been denied. They recently started trying to cite a policy in the "2022 Utah Medicaid Provider Manual" saying that everything is carved out to the state. There is nothing it the manual regarding any carve-outs for UDT. I have no idea what they're talking about.
I'm in the process of appealing another claim and then escalating it as high as I can. I had to stop working on the original appeals process because of the disastrous NCCI edit situation. I wanted to check and see if anybody else has seen this before or has any suggestions. I think I've done everything right here but maybe I'm missing something? I don't know.
Thanks yall.