During a program integrity post payment review, Community Health Plan of Washington (CHPW) identified claims for definitive urine drug testing performed on the same day as presumptive urine drug testing.
CHPW follows our Clinical Coverage Criteria Policy MM170, Urine Drug Testing in Addiction Treatment, to determine if definitive urine drug testing on the same day as presumptive testing is medically necessary. This policy applies for our Medicaid, Medicare Advantage, and Community Health Network of Washington (CHNW) Cascade Select plans. Providers may access this policy on our Clinical Coverage Criteria webpage, https://www.chpw.org/provider-center/prior-authorization/medication-management/.
The policy states:
“Definitive testing must only be ordered in specific documented situations in which definitive testing is required for clinical decision making; and is appropriate as indicated by 1 or more of the following:
- “Unexpected and unexplained negative presumptive testing and 1 or more of the following:
- Positive test was expected due to prescribed medication (such as buprenorphine)
- Negative presumptive test but concern for false negative test based on patient behavior, testing outside of the window of detection, lack of sensitivity, or lab abnormality.
- “Confirmation of positive presumptive test when patient denies using substance”
Stated another way: If a presumptive test is ordered, a definitive test on the same day is only medically necessary if there is an unexpected result of the presumptive test as defined above that cannot be explained by a discussion between the provider and the patient.
CHPW requires the following to determine if definitive testing was medically necessary:
- The provider must submit medical records for the date of service and the date the definitive testing was ordered.
- The records must also show the results of the discussion of the unexpected presumptive testing results with the patient.
In addition, please see WAC 182-500-0070 for a definition of “medically necessary.”
CHPW is updating our claims system so that codes for presumptive testing and definitive testing are not allowed in combination on the same date. Using our normal two-year look back period, this change becomes effective for dates of service January 1, 2019 and forward for Medicaid and Medicare Advantage plans; or dates of service January 1, 2021 and forward for Cascade Select plans. Those claims will be denied using denial code, “Definitive drug testing is not allowed on the same date as presumptive drug testing.”
CHPW will continue to review claims and medical records retrospectively for claims that were processed before our claims system was updated. If the criteria were not met, then the definitive testing was not medically necessary, and we will recoup payment for definitive testing.
If you have any questions about this bulletin or about CHPW’s Urine Drug Testing in Addiction Treatment policy, please contact:
- CHPW Washington Apple Health Integrated Managed Care (IMC) Customer Service, 1 (800) 440-1561
- CHPW Medicare Advantage Customer Service, 1 (800) 942-0247
- CHNW Cascade Select Customer Service, 1 (866) 907-1906
