MedicaidReimbursementHigh impact
23-013 Bill Correctly to Get Paid for Pulmonary Testing and Skin Substitute Claims
Health Net·CA · Pulmonology, Wound Care, Plastic Surgery +1 more·Reimbursement
Effective date
Mar 15, 2023
We identified it
Jun 20, 2026
Summary
Health Net is implementing new payment edits effective March 15, 2023, for pulmonary function testing (requiring medical necessity compliance) and skin substitute claims (requiring specific application codes based on high/low cost categories). Claims must follow Medi-Cal and CMS coding guidelines or face payment denials.
Action Required
Immediately: Billing team must update system to ensure pulmonary function testing claims include medical necessity documentation per policy CP.MP.242. For skin substitute claims, verify high-cost products are only billed with CPT codes 15271-15278, and low-cost products only with HCPCS codes C5271-C5278. Update billing software edits to match Medi-Cal and CMS guidelines. Claims not meeting these requirements will face payment denials or retrospective reviews.