HealthKeepers, Inc. | Anthem HealthKeepers Plus Medicaid productsAugust 3, 2023
Change to ostomy and colostomy products and accessories
Please note, this communication applies to Anthem HealthKeepers Plus Medicaid products offered by HealthKeepers, Inc.
Effective November 1, 2023, HealthKeepers, Inc. will align the benefit limits for ostomy and colostomy products and accessories with Virginia Department of Medical Assistance Services (DMAS) benefit limits. The affected codes are listed below. This change will affect the current reimbursement policy and related claims processing rules associated with the listed codes.
HealthKeepers, Inc. will no longer reimburse for any 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:
Ostomy and colostomy pouches and accessory supplies | |||
| Code | Description | Billing unit | DMAS limit |
Ostomy/colostomy products/ostomy accessories | |||
A4216 | Sterile water, saline and /or dextrose, diluent/flush, 10 ml | Each | 60/Month |
A4217 | Sterile water/saline 500 ml | Each | 60/Months |
A4361 | Ostomy Face Plate | Each | 2/3 Months |
A4363 | Ostomy clamp, any type, replacement only, each | Each | 3/2 Months |
A4366 | Ostomy vent, any type, each | Each | 20/Month |
A4367 | Ostomy Belt | Each | 1/Month |
A4368 | Ostomy filter, any type, each | Each | 20/Month |
A4394 | Ostomy deodorant, with or without lubricant, for use in ostomy pouch, per fluid ounce | Ounce | 8/Month |
A4395 | Ostomy deodorant for use in Ostomy pouch, solid. Per tablet | Each | 50 each/Month |
A4396 | Ostomy belt with peristomal hernia support | Each | 1/Month |
A4398 | Ostomy irrigation supply; bag; each | Each | 4 per year |
A4399 | Ostomy Irrigation Bag, cone/catheter, including brush | Each | 4 per year |
A4400 | Ostomy Irrigation Set | Each | 1/6 Months |
A4404 | Ostomy Rings All Sizes | Each | 10/Month |
A4422 | Ostomy absorbent material (sheet/pad/crystal packet), for use on Ostomy pouch to thicken liquid stoma output, each | Each | 100/2 Months |
A4436 | Irrigation supply; Sleeve, reusable, per month | 1 unit = 1 month supply | 1/Month |
A4437 | Irrigation supply; sleeve, disposable, per month | 1 unit = 1 month supply | 1/ Month |
A4456 | Adhesive Remover, Wipes, any type, each | Each | 50/Month |
A4455 | Adhesive Remover or Solvent (for tape, cement or other adhesive), | Ounce | 31 oz per year |
A5055 | Stoma Caps | Each | 31/Month |
A5056 | Ostomy Pouch, Drainable, with extended wear barrier attached, with filter (1 piece) each | Each | 50/Month |
A5057 | Ostomy Pouch, drainable, with extended wear barrier attached, with built in convexity, with filter, (1 piece) each | Each | 50/Month |
A5081 | Continent device; plug for continent stoma | Each | 31/Month |
A5082 | Continent device; catheter for continent stoma | Each | 1/Month |
A5083 | Continent device, stoma absorptive cover for continent stoma | Each | 180/Month |
A5093 | Ostomy Accessory, Convex Insert | Each | 10/Month |
A5102 | Bedside drainage bottle, with or without tubing, rigid or expandable, each | Each | 4 per year |
A5105 | Urinary suspensory with leg bag, with or without tube, each | Each | 1/Month |
A5126 | Adhesive or non-adhesive; Disc or Foam Pad | Each | 20/Month |
A5131 | Appliance cleaner, incontinence and Ostomy appliances, per 16 oz | Btl. (16oz.) | 1/Month |
A5200 | Percutaneous catheter/tube anchoring device, adhesive skin attachment | Each | 2/Month |
Ostomy pouches | |||
A4330 | Perianal Fecal Collection Pouch with Adhesive | Each | 31/Month |
A4375 | Ostomy pouch, drainable, with faceplate attached, plastic, each | Each | 20/Month |
A4376 | Ostomy pouch, drainable, with faceplate attached, rubber, each | Each | 20/Month |
A4377 | Ostomy pouch, drainable, for use on faceplate, plastic, each | Each | 10/month |
A4378 | Ostomy pouch, drainable, for use on faceplate rubber, each | Each | 3/month |
A4379 | Ostomy pouch urinary, with faceplate attached, plastic, each | Each | 10/Month |
A4380 | Ostomy pouch urinary, with faceplate attached, rubber, each | Each | 3/Month |
A4381 | Ostomy pouch urinary, for use on faceplate, plastic, each | Each | 10/Month |
A4382 | Ostomy pouch urinary, for use on faceplate, heavy plastic, each | Each | 20/Month |
A4383 | Ostomy pouch urinary, for use on faceplate, rubber, each | Each | 3/Month |
A4387 | Ostomy pouch, closed, with barrier attached, with built in convexity (one piece), each | Each | 60/Month |
A4388 | Ostomy pouch, drainable, with extended wear barrier attached, (one piece), each | Each | 20/Month |
A4389 | Ostomy pouch drainable, with barrier attached, with built in convexity (one piece), each | Each | 20/Month |
A4390 | Ostomy pouch, drainable, with extended wear barrier attached, with built in convexity (1 piece), each | Each | 20/Month |
A4391 | Ostomy pouch, urinary, with extended wear barrier attached (1 piece), each | Each | 20/Month |
A4392 | Ostomy pouch, urinary, with standard wear barrier attached, with built in convexity (1 piece), each | Each | 20/Month |
A4393 | Ostomy pouch, urinary, with extended wear barrier attached, with built in convexity, (1 piece), each | Each | 20/Month |
A4411 | Ostomy skin barrier, solid 4x4 or equivalent, extended wear, with built-in convexity, each | Each | 20/Month |
A4412 | Ostomy pouch, drainable, high output, for use on a barrier with flange, (2-piece system), without filter, each | Each | 20/Month |
A4413 | Ostomy pouch, drainable, high output, for use on a barrier with flange, (2-piece system), with filter, each | Each | 20/Month |
A4416 | Ostomy pouch, closed, with barrier attached, with filter (one piece), each | Each | 60/Month |
A4417 | Ostomy pouch, closed, with barrier attached, with built in convexity, with filter (one piece), each | Each | 60/Month |
A4418 | Ostomy pouch, closed; without barrier attached, with filter (one piece), each | Each | 60/Month |
A4419 | Ostomy pouch, closed; for use on barrier with non-locking flange, with filter (two piece), each | Each | 60/Month |
A4420 | Ostomy pouch, closed; for use on barrier with locking flange, (two piece), each | Each | 60/Month |
A4423 | Ostomy pouch, closed; for use on barrier with locking flange, with filter (two piece), each | Each | 60/Month |
A4424 | Ostomy pouch, drainable, with barrier attached, with filter (one piece), each | Each | 20/Month |
A4425 | Ostomy pouch, drainable, for use on barrier with non-locking flange, with filter (two-piece system), each | Each | 20/Month |
A4426 | Ostomy pouch drainable, for use on barrier with locking flange, (two-piece system), each | Each | 20/Month |
A4427 | Ostomy pouch drainable, for use on barrier with locking flange, with filter (two-piece system), each | Each | 20/Month |
A4428 | Ostomy pouch, urinary, with extended wear barrier attached, with faucet – type tap with valve (one piece), each | Each | 20/Month |
A4429 | Ostomy pouch, urinary, with barrier attached with built in convexity, with faucet – type tap with valve (one piece), each | Each | 20/Month |
A4430 | Ostomy pouch, urinary, with extended wear barrier attached with built in convexity, with faucet – type tap with valve (one piece), each | Each | 20/Month |
A4431 | Ostomy pouch, urinary, with barrier attached with faucet – type tap with valve (one piece), each | Each | 20/Month |
A4432 | Ostomy pouch, urinary; for use on barrier with non-locking flange, with faucet – type tap with valve (two piece), each | Each | 20/Month |
A4433 | Ostomy pouch, urinary; for use on barrier with locking flange, (two piece), each | Each | 20/Month |
A4434 | Ostomy pouch, urinary; for use on barrier with locking flange, with faucet – type tap with valve (two piece), each | Each | 20/Month |
A4435 | Ostomy pouch, drainable, high output, with extended wear barrier (one-piece system), with or without filer, each | Each | 20/Month |
A5051 | Ostomy Pouch, Closed w/Barriers Attached, 1 Piece | Each | 60/Month |
A5052 | Ostomy Pouch Closed without Barrier Attached, 1 Piece | Each | 60/Month |
A5053 | Ostomy Pouch, Closed for Use on Face Plate | Each | 60/Month |
A5054 | Ostomy Pouch Closed for Use on A Barrier with Flange, 2 Pieces, does not say closed or mini pouch | Each | 60/Month |
A5061 | Ostomy Pouch, Drainable, W/Barrier Attached; 1 piece | Each | 20/Month |
A5062 | Ostomy Pouch, Drainable without Barrier Attached, 1 Piece | Each | 20/Month |
A5063 | Ostomy Pouch, Drainable, for Use on Barrier W/Flange, 2 Piece System | Each | 20/Month |
A5071 | Ostomy Pouch Urinary w/Barrier Attached 1 Piece | Each | 20/Month |
A5072 | Ostomy Pouch Urinary without Barrier Attached, 1 Piece | Each | 20/Month |
A5073 | Ostomy Pouch Urinary for Use on Barrier with Flange, 2 Pieces | Each | 20/Month |
Ostomy skin barrier liquids, pastes, powder, and rings | |||
A4362 | Ostomy Skin Barrier; Solid, 4x4 or Equivalent | Each | 20/Month |
A4364 | Adhesive liquid or equal, any type | Ounce | 4 Ounces/Month |
A4369 | Ostomy skin barrier, liquid (spray, brush, etc.), per oz. | Ounce | 2 Ounces Month |
A4371 | Ostomy skin barrier powder, per oz. | Ounce | 2 Ounces Month |
A4372 | Ostomy skin barrier, solid 4x4 or equivalent, with built-in convexity, each | Each | 20/Month |
A4373 | Ostomy skin barrier, with flange (solid, flexible, or accordion), with built-in convexity, any size, each | Each | 20/Month |
A4384 | Ostomy faceplate equivalent, silicone ring, each | Each | 3/Month |
A4385 | Ostomy skin barrier, solid 4X4 or equivalent, extended wear, without built-in convexity, each | Each | 20/Month |
A4405 | Ostomy skin barrier, non-pectin based, paste, per ounce | Ounce | 4 Ounces/Month |
A4406 | Ostomy skin barrier, pectin-based, paste, per ounce | Ounce | 4 Ounces/Month |
A4407 | Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built in convexity, 4x4 inches or smaller, each | Each | 20/Month |
A4408 | Ostomy skin barrier, with flange (solid, flexible, or accordion), extended wear, with built in convexity, larger than, 4x4 inches, each | Each | 20/Month |
A4409 | Ostomy skin barrier, with flange, (solid, flexible, or accordion), extended wear, without built-in convexity, 4X4 inches or smaller, each | Each | 20/Month |
A4410 | Ostomy skin barrier, with flange, (solid, flexible, or accordion), extended wear, without built-in convexity, larger than 4X4 inches, each | Each | 20/Month |
A4414 | Ostomy skin barrier, with flange (solid, flexible, or accordion), without built in convexity 4x4 inches or smaller, each | Each | 20/Month |
A4415 | Ostomy skin barrier, with flange (solid, flexible, or accordion), without built in convexity, larger than 4x4 inches, each | Each | 20/Month |
A5120 | Skin Barrier Wipes or swabs, each | Each | 30/Month |
A5121 | Skin Barrier, Solid 6x6 or Equiv. | Each | 20/Month |
A5122 | Skin Barrier, solid, 8x8 or Equivalent | Each | 20/Month |
If you have any questions about this communication, call Anthem HealthKeepers Plus Provider Services at 800-901-0020.
VABCBS-CD-032450-23
PUBLICATIONS: September 2023 Provider Newsletter
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