HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsJuly 1, 2022
Change to Department of Medical Assistance Services’ incontinence undergarment benefit limits
Please note, this communication applies to Anthem HealthKeepers Plus, Medallion and Anthem HealthKeepers Plus, Commonwealth Coordinated Care Plus (Anthem CCC Plus) offered by HealthKeepers, Inc.
Effective July 1, 2022, HealthKeepers, Inc. will align the benefit limits for incontinence undergarments with Virginia Department of Medical Assistance Services (DMAS) benefit limits. The list of impacted codes is noted below. This change will affect the current reimbursement policy and related claims processing rules associated with incontinence undergarments.
HealthKeepers, Inc. will no longer reimburse for any supply amount that exceeds the DMAS benefit limits for Anthem HealthKeepers Plus members.
HealthKeepers, Inc. will only reimburse providers for quantities exceeding DMAS limits when prescribed by a physician, documented on a Certificate of Medical Necessity (CMN), and authorized by HealthKeepers, Inc. HealthKeepers, Inc. follows the same criteria as DMAS in determining all medical necessity approval.
We recommend that providers visit the online provider manual to review all authorization, appeals, and reconsideration processes at:
https://providers.anthem.com/docs/gpp/VA_CAID_ProviderManual.pdf?v=202105212022.
Code |
Description |
DMAS limit |
T4536 |
Incontinence product, protective underwear/pull-on, reusable, any size |
14 per year |
T4537 |
Incontinence product, protective underpad, reusable, bed size |
6 per year |
T4539 |
Incontinence product, diaper brief, reusable any size |
14 per year |
T4540 |
Incontinence product, protective Under pad, reusable, chair size |
6 per year |
A4554* |
Disposable under pads, All sizes,150 per case |
1 case per month |
T4541* |
Incontinence product, disposable underpad, large |
1 case per month |
T4542* |
Incontinence product, disposable underpad, small |
1 case per month |
* Chux codes (A4554, T4541, T4542) will not be allowed/payable in conjunction with any of the 19 disposable incontinence undergarment codes.
Code |
Description |
DMAS Limit |
T4521 |
Adult size disposable incontinence product, brief/diaper, small |
180 per month |
T4522 |
Adult size disposable incontinence product, brief/diaper, medium |
180 per month |
T4523 |
Adult size disposable incontinence product, brief/diaper, large |
180 per month |
T4524 |
Adult size disposable incontinence product, brief/diaper, extra-large, extra absorbent |
180 per month |
T4525 |
Adult size disposable incontinence product, protective underwear/pull-on, small |
180 per month |
T4526 |
Adult size disposable incontinence product, protective underwear/pull-on, medium |
180 per month |
T4527 |
Adult size disposable incontinence product, protective underwear/pull-on, large |
180 per month |
T4528 |
Adult size disposable incontinence product, protective underwear/pull-on, extra large |
180 per month |
T4529 |
Pediatric sized disposable incontinence product, brief/diaper, small or medium, extra absorbent |
180 per month |
T4530 |
Pediatric sized disposable incontinence product, brief/diaper, large or extra-large, extra absorbent |
180 per month |
T4535 |
Panty liners, extra absorbent |
180 per month |
T4531 |
Pediatric size disposable incontinence product, protective underwear/pull-on, small/medium size, each |
180 per month |
T4532 |
Pediatric size disposable incontinence product, protective underwear/pull-on, large size, each |
180 per month |
T4533 |
Youth sized disposable incontinence product, brief/diaper |
180 per month |
T4534 |
Youth sized disposable incontinence product, protective underwear/pull-on |
180 per month |
T4535 |
Disposable liner/shield/guard/pad/undergarment, for incontinence, each |
180 per month |
T4543 |
Adult sized disposable incontinence product, protective brief/diaper, above extra large |
180 per month |
T4544 |
Adult sized disposable incontinence product, protective underwear/pull-on, above extra large |
180 per month |
A4335 |
Incontinence supplies, not otherwise specified |
180 per month |
If you have any questions about this communication, call Anthem HealthKeepers Plus, Medallion Provider Services at 800-901-0020 or Anthem CCC Plus Provider Services at 855-323-4687.
PUBLICATIONS: July 2022 Anthem Provider News - Virginia
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