Do most of your patients use insurance when coming to your practice? If so, here are a few key policies to note as providers and office staff:

Anthem

  • Will NOT cover a drug confirmation without a drug screen
  • WILL cover a drug screen and drug confirmation (in addition to non-detected prescribed medications, and medications that ac screen cannot detect) based on the criteria in the Urine Drug Testing Medicare policy (see below)

Aetna 

  • Screen + tier 1 and tier 2 are allowed
  • Submit clinical records with the claim that substantiates the medical necessity of the test, records must include a specific list of drug classes in question
  • Definitive testing is medically indicated when: the presumptive test was negative for a prescribed medications and the patient disputes the results, OR the presumptive test was positive for a prescription drug with abuse potential that was not prescribed AND the patient disputes the result, OR the presumptive test was positive for an illegal drug AND the patient disputes the results

Cigna

  • Presumptive drug testing not to exceed one unit per date of service up to 32 unites per year is considered medically necessary when there is a suspicion of drug misuse by the individual being tested and ALL of the following criteria are met:
    • The diagnosis, history, and physical examination and or behavior of the individual being tested support the need for the specific drug testing being requested
    • The results of testing will impact treatment planning
    • Testing is performed in a physician-supervised treatment setting
  • Definitive drug testing not to exceed 16 dates of service per year for a maximum of eight units may include specific individual drug and/or its metabolite, or its structural isomer per date of service up to 128 units per year is considered as medically necessary when there is suspicion of drug misuse by the individual being tested and EITHER of the following criteria are met:
    • Presumptive test results are inconsistent with the individuals condition, history and examination
    • Presumptive drug test is not available for the drug for which there is a suspicion of abuse or misuse and ALL of the following criteria are met:
      • the diagnosis, history, and physical examination and or behavior of the individual being tested support the need for the specific drug testing being requested
      • results of testing will impact treatment planning
      • testing is performed in a physician-supervised treatment setting

Humana-CareSource

  • Humana-CareSource will reimburse up to 25 UDT in a calendar year for each member
    • Each CPT code is counted as one test toward the 25 total drug tests in a calendar year
    • UDT G0482 and G0483 (requiring a PA as noted above) will also count toward the 25 total UDT in a calendar year
  • Drug testing should be focused on the detection of specific drugs and not routinely include a panel of all drugs of abuse
  • Orders for “custom profiles’, ‘standing orders’, “drug screen panel”, etc. are not billable to and will not be reimbursed by Humana-CareSource
  • Testing on a routine basis is netieth random nor individualized. Routine or refled testing is NOT billable to and will not be reimbursed by Humana-CareSource. A random basis is defined as a basis which the patient cannot predict ahead of time. For example, testing performed at every clinical visit is not random.
  • Routine multi-drug definitive/quantitative testing is not billable and will not be reimbursed by Humana-CareSource
  • Definitive/quantitative testing must be individualized for the member and medically necessary

Medicare Guidelines and Policies for Urine Drug Testing:

 

 

 

 

 

 

 

 

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