Physical exams for employment, insurance, or licensing is a non-covered service for Apple Health Integrated Managed Care or Apple Health Expansion plans.
The following diagnosis codes are commonly used for these non-covered physical exams; these services are excluded per the Washington State Health Care Authority (HCA) and are listed as not covered on the fee schedule:
- Z02.1, Encounter for pre-employment examination
- Z02.4, Encounter for examination for driving license
- Z02.6, Encounter for examination for insurance purposes
Non-covered services that are billed to CHPW are normally denied as “benefit or service not covered”. However, CHPW identified some claims that were billed and paid in error for physical exams relevant to employment, insurance, and licensing – CHPW is in the process of adjusting those claims going back 2 years to August 2022.
Providers are permitted to bill Apple Health members if required procedures are followed, which includes completing the HCA 13-879 form prior to rendering services. This Agreement and WAC 182-502-0160 apply to billing a client for covered and noncovered services as described in WAC 182-501-0050 through WAC 182-501-0070. Following is a link to the HCA 13-879 Form: HCA 13-879 Form
For questions, please contact Customer Service at (800) 440-1561 or email [email protected].
