Medical & Reimbursement Policies
Medical Policy
Policy Id
Topic
Section
Effective Date
Issued Date
Last Revision Date
DISCLAIMER
Highmark medical policy is intended to serve only as a general reference resource regarding coverage for the services described. This policy does not constitute medical advice and is not intended to govern or otherwise influence medical decisions.
POLICY STATEMENT
This policy provides information regarding the coverage of, as determined by applicable federal and/or state legislation.
This policy is designed to address medical necessity guidelines that are appropriate for the majority of individuals with a particular disease, illness or condition. Each person’s unique clinical circumstances warrant individual consideration, based upon review of applicable medical records.
The qualifications of the policy will meet the standards of the National Committee for Quality Assurance (NCQA) and the Delaware Department of Health and Social Services (DHSS) and all applicable state and federal regulations.
Purpose
This medical policy outlines Highmark Health Options Duals services for Pulmonary Rehabilitation.
Definitions
Highmark Health Options Duals (HHO Duals) – Highmark Health Options Duals is designed for people with both Medicare and Medicaid. Our D-SNP Medicare Advantage HMO coverage offers the same benefits as Original Medicare, plus extra benefits, like prescription drug coverage and vision and dental care.
Prior Authorization
Prior authorization is not required.
Procedures
Please review the specific National Coverage Determination (NCD), Local Coverage Determination (LCD), and/or Local Coverage Article (LCA) information, as well as other CMS sources, using the links below.
Post-payment Audit Statement
The medical record must include documentation that reflects the medical necessity criteria and is subject to audit by HHO Duals at any time pursuant to the terms of your provider agreement.
Place of Service
The proper place of service for pulmonary rehabilitation is an outpatient program based in a hospital or clinic setting.
Coverage Determination and Links
HHO Duals follows the coverage determinations made by CMS as outlined in either the NCD and/or the state-specific LCD/LCA.
CMS Link
NCD/LCD Link
· NCD: Pulmonary Rehabilitation Services (240.8)
· There are no LCDs related to this topic.
Transmittal Link
CMS Transmittal: Transmittal 78 (Medicare Claims Processing)
Reimbursement
Participating facilities will be reimbursed per their HHO Duals contract.
References
Centers for Medicare and Medicaid Services (CMS). National Coverage Determination (NCD) for Pulmonary Rehabilitation Services (240.8). Effective Date September 25, 2007. Accessed on April 229, 2024
Centers for Medicare and Medicaid Services (CMS). Transmittal 78. Effective Date December 5, 2007. Accessed on April 29, 2024
Contact Us
For questions related to this policy, contact the Highmark Government Market Policy Team at GovernmentPolicy@Highmark.com
