Updated Healthchoice Very Low Birth Weight Delivery Payment Policy and Billing Process, Effective January 1, 2022

By January 1, 2022 (retroactive to effective date): Billing team must implement the following: (1) Update billing system to require U5 modifier on all VLBW claims for dates of service on or after January 1, 2022 with procedure codes MC001 (Baltimore City), MR001 (Montgomery County), or MS001 (All Other Counties/Rest of State); (2) Establish monthly submission process to mdh.mof@maryland.gov of encrypted VLBW Newborn Tracking Sheet, CMS 1500 claim forms, and 4518a adjustment forms (if applicable) using specified naming convention; (3) Ensure all CMS 1500 claims include required ICD-10 diagnosis codes P07-P07.15 (VLBW) and Z3A-Z3A.49 (Gestation) in Box 21; (4) Train billing staff on enhanced payment criteria for first VLBW deliveries (gestational age ≥21 weeks, weight <1500 grams) and subsequent VLBW deliveries (which require documentation of prior spontaneous preterm delivery, singleton pregnancy, and hydroxyprogesterone caproate or vaginal progesterone administration between 16-24 weeks gestation continued until delivery or week 37); (5) Implement documentation requirements for VLBW2+ payments including prenatal visit notes, claim evidence of progesterone administration, delivery notes, and home visit notes from Optum or other providers; (6) Establish process to monitor claim status via eMedicaid weekly remittance advice (https://encrypt.emdhealthchoice.org/emedicaid/) and contact Provider Relations at (410) 767-5503 or (800) 445-1159 Option 2 for claim denials or discrepancies. Failure to submit required documentation, use incorrect modifiers, or include required diagnosis codes will result in claim denials and non-reimbursement.