CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Urine Toxicology Testing Cmp 6.1.2016 12.31.2022

Defines coverage policy for urine toxicology screening (immunoassay/qualitative) and confirmatory quantitative testing for specified Neighborhood Health Plan of Rhode Island lines of business, including medical necessity criteria, exclusions, and prior authorization guidance.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyUrine Toxicology Testing Cmp 6.1.2016 12.31.2022

Policy CodePolicy N/A

Change TypeRevised (12/8/21)

Effective DateJul 14, 2016

Next Review Date

Key ActionMedical records must document the medical necessity of billed qualitative or quantitative urine toxicology tests.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed and revised on 12/8/21 (also prior revision dates listed).

6Lines of business covered

1Lines of business excluded

4Listed clinical indications for qualitative testing

Coverage Summary

Overview: This policy defines coverage for Urine Toxicology Testing (Qualitative and Quantitative) including immunoassay (qualitative) screening and laboratory-based quantitative/confirmatory testing for specified Neighborhood Health Plan of Rhode Island lines of business. Effective date: 2016-07-14. Last review: 2021-12-08. Coverage stance: mixed.

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Medical-Necessity Criteria

Qualitative (Immunoassay) Urine Drug Testing - Medically Necessary

Qualitative urine drug testing is considered medically necessary when ALL of the following conditions are met:

ONE of

An individual is receiving treatment for chronic pain with prescription opioid or other medication associated with increased risk for misuse or addiction
An individual is undergoing treatment for substance use disorder or is otherwise requiring monitoring for use/misuse of controlled or illicit substance(s)
Misuse of prescribed or illicit substances is suspected
An individual is beginning a pain management program or substance use disorder treatment program

ALL of the following

Medical records must document the medical necessity of billed services
Testing should be performed at point of service (POC); immunoassay performed in a laboratory setting is NOT medically necessary

Quantitative (Confirmatory) Urine Drug Testing - Medically Necessary

Quantitative/confirmatory testing is considered medically necessary when ALL of the following are met:

ONE of

Unexpected positive test inadequately explained by the patient
Unexpected negative test (suspected medication diversion)
Need for quantitative levels to compare with established benchmarks for clinical decision making

ALL of the following

Quantitative or confirmatory testing must be ordered on an individual basis by a medical provider directly caring for the member at the time of order (no standing/routine orders)

Exclusions / Not Eligible for Reimbursement

Exclusions - Not Eligible for Reimbursement

The following are not eligible for reimbursement:

ANY of the following

Qualitative testing that is required for or part of participation in a substance use disorder treatment program with an all-inclusive bundled rate
Routine testing (i.e., testing at every visit)
Testing ordered by or for third parties for the sole purpose of meeting the requirements of a third party
Routine quantitative drug testing (i.e., testing at each visit)
Quantitative testing when qualitative testing is clinically appropriate and meets clinical needs
Routine confirmatory testing in the absence of an unexpected positive finding or an unexpected negative finding

Specimen Validity & Billing Guidance

Specimen Validity Testing Billing Guidance

Operational billing guidance per Medicare instructions:

Drug testing providers performing validity testing on urine specimens utilized for drug testing should not separately bill the validity testing if performed as part of confirming specimen integrity (e.g., urinary pH, specific gravity, creatinine, nitrates, oxidants)

Billing Rule

Specimen validity testing not separately billable

Validity testing (urinary pH, specific gravity, creatinine, nitrates, oxidants, etc.) performed to confirm specimen integrity should not be separately reported or billed.

Provider Actions

Documentation Required

Medical record documentation required

Medical records must document the medical necessity of billed qualitative or quantitative urine toxicology tests.

Prior Authorization

Prior authorization resources and contact

Prior Authorization forms available on Neighborhood website; for assistance contact Clinical Administrative Support at 401-459-6060 and fax authorization forms to 401-459-6023.

Denial Risk

Denial risk for routine or third-party-directed testing

Claims for routine testing, routine quantitative testing, or tests ordered solely to meet third-party requirements are not eligible for reimbursement and may be denied.

Background

Background: Urine toxicology testing includes immunoassay (qualitative) screening and quantitative confirmatory testing (e.g., GC/MS). Immunoassays are preferred at point of care and provide rapid, qualitative (positive/negative relative to a threshold) results; they are the usual initial screen. Confirmatory quantitative testing is laboratory-based and used to identify and quantify specific drugs or metabolites when clinically indicated.

Definition - Immunoassay Testing: Qualitative screening using antibodies to detect presence of a drug/drug class or metabolites, typically performed at point of service and reported as positive/negative relative to a threshold.

Definition - Quantitative/Confirmatory Testing: Laboratory-based testing (e.g., GC/MS) that identifies and quantifies specific drugs or metabolites; used to confirm screening results or when specific drug identification/quantification is needed.