CurrentBlue Cross Blue Shield - NevadaPolicy G-06111

Medical Recalls, Reimbursement Policy

This policy governs Anthem Medicare Advantage reimbursement for repair, replacement, removal, and replacement procedures related to medically recalled durable medical equipment and items for covered members. It applies to providers submitting claims to Anthem Medicare Advantage in the listed states.

Policy Summary

PayerBlue Cross Blue Shield - Nevada

PolicyMedical Recalls, Reimbursement Policy

Policy CodePolicy G-06111

Change TypeAdded itemsclarified payment reduction

Effective DateMay 22, 2024

Next Review Date

Key ActionWhen applicable, providers should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item.

SourceLink

POLICY UPDATE CHANGES

Added implantable devices under applicable items.

Clarified payment reduction when facilities receive partial or full credit for a recalled device or item.

11 statesgeographic applicability

5item categories

2006-2024policy history

Reimbursement Criteria for Recalled Items

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Reimbursement for repair or replacement of items due to a medical recall is not allowed unless provider, state, federal, or CMS contracts or requirements indicate otherwise.

Applicable recalled item categories include: supplies; orthotics; prosthetics; drugs/vaccines; and implantable devices.

Anthem will allow reimbursement for medically necessary procedures to remove and replace recalled or replaced devices or items.

If an inpatient or outpatient facility receives full or partial credit for a replaced device or item due to recall, payment to the facility will be reduced by the amount of the device or item credit.

When Anthem has reimbursed a provider for recall-related repairs, replacements, or procedures and later receives recoupment from a manufacturer or distributor, Anthem is entitled to recover fees from that manufacturer and/or distributor.

If Anthem reimbursed a provider for the full or partial cost of a replaced device or item and the provider subsequently receives full or partial credit for that device or item, Anthem is entitled to recoup or recover fees from the provider.

When applicable, providers should bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify a medically recalled item.

Billing, Authorization, and Provider Requirements

Billing Rule

Bill appropriate codes to identify recalled items

When a claim involves a medically recalled device or item, bill the appropriate condition code, value code, modifier, and/or diagnosis code to identify the recalled item on the claim form.

Use industry-standard CPT/HCPCS/revenue codes and append the appropriate condition/value/modifier/diagnosis code to denote the recalled item.

Prior Authorization

Ensure authorization, medical necessity, and proper coding

Services must meet authorization and medical necessity guidelines appropriate to the procedure, diagnosis, and the member's state of residence; use industry-standard, compliant codes on all claim submissions and support billed services in the medical record.

Follow authorization and medical necessity requirements for the procedure and diagnosis.
Use CPT, HCPCS, and revenue codes that are fully supported in the medical record or office notes.

Definitions

Definitions — General Reimbursement Policy Definitions (referenced)

Referenced definitionsGeneral Reimbursement Policy Definitions as listed in the policy's Definitions section.

Purpose of definitionsProvide standardized meanings for terms used throughout Anthem Medicare Advantage reimbursement policies.

ScopeApplies to Anthem Medicare Advantage reimbursement policies governing recalls, credits, recoupment, and related procedures.

LocationSee the policy's Definitions section for the full set of General Reimbursement Policy Definitions referenced here.

Use in interpretationDefinitions inform coverage determinations, coding expectations, and recoupment processes described in this policy.