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.

 

VAHK-CAID-000094-22



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July 2022 Anthem Provider News - Virginia