Billing Guideline for Circumcision—Apple Health Integrated Managed Care (Medicaid)
Community Health Plan of Washington (CHPW) is excited to announce a new value-added benefit for CHPW Apple Health Integrated Managed Care (Medicaid) members: For services starting February 1, 2021, CHPW will pay up to $200.00 for non-medically necessary circumcision.
Billing Details
- Male children under 18 years of age are eligible.
- This is a once per lifetime $200.00 maximum benefit for each member. Regardless of how many male children a mother has in her family, each is eligible for the benefit.
- Members may obtain this service from an open network. The provider does not have to be contracted with CHPW; they just need to be willing to bill CHPW and must have a Core Provider Agreement with the Health Care Authority (https://www.hca.wa.gov/assets/billers-and-providers/09-015-core-provider-agreement.pdf).
- CHPW will process claims for professional, surgery, facility, anesthesia, and other associated charges in the order received.
- Once the $200.00 is met, any subsequent related claims received for the same member will be denied as “benefit maximum reached” and the charges will be the patient’s responsibility.
- If CHPW receives the professional claim first, we will pay that in full up to the allowed amount and apply any remaining dollars up to the $200.00 maximum on subsequent claims.
Example
$75.00 Professional fee billed
$50.00 Allowed amount
——————————————————————————————
$50.00 CHPW payment amount subtotal
$300.00 Facility claim billed
$250.00 Allowed amount
——————————————————————————————
$150.00 CHPW payment amount subtotal
_______________________________________________________
$200.00 total CHPW payment amount (professional + facility fees)
• CHPW will pay for services associated with any complication from the procedure as part of the medical benefit.
• Claims for non-medically necessary circumcision submitted prior to February 1, 2021 will continue to be denied.
Questions?
Our Customer Service Team is ready to help with any questions that you or your patient may have. You can reach them by email at [email protected] or at the phone number below during business hours.
Apple Health Integrated Managed Care
• Phone number: 1-800-440-1561
• Business hours: Monday through Friday from 8 am to 5 pm
