Claims

Medicaid Members are not to be being balanced billed.

Sick and well visit in the same day: When providers provide a disease-related or problem-oriented service visit, the MCOs will reimburse the preventive medicine service plus one of the following problem-oriented evaluation and management (E/M) service codes if you append it with modifier 25 to indicate you provided a significant, separately identifiable E/M service on the same day you provided the preventive medicine service.
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This applies to services provided for the same member on the same day by a physician or other qualified health care professional in the same group or specialty with the same Federal Tax ID number. When billing:

• Enter the modifier 25 in box 24d of CMS Form 1500 along with the E/M service code.
• Keep the E/M service documentation separate from the preventive service documentation.
• Link the appropriate ICD-9 code to the applicable current procedural terminology code listed below.

Claims Reconsiderations should be submitted per MCO as follows: