Name of Manual - Blue Cross and Blue Shield of Minnesota

Health Care Home
(HCH) (continued)
Coding Policies and Guidelines (Medical Services)
2. For code S0281: Allow once per month for subsequent
months. No patient out of pocket should be applied. The
code will be allowed per provider contract. Code S0281
billed more than once per month for each patient will be
denied with Claim Adjustment Reason Code 119 and
Remark Code M86.
Subscribers who are not covered under an HSA plan members:
1. For code S0280: Allow once per 12 months for each
patient/provider combination. Patient
deductible/coinsurance will apply per Internal Revenue
Service (IRS) regulations. The code will be allowed per
provider contract. Code S0280 billed more than once per
12 months for each patient /provider combination will be
denied with Claim Adjustment Reason Code 119 and
Remark Code M90.
2. For code S0281: Allow once per month for subsequent
months. Patient deductible/coinsurance will apply per IRS
regulations. The code will be allowed per provider contract.
Code S0281 billed more than once per month for each
patient will be denied with Claim Adjustment Reason Code
119 and Remark Code M86.
Coding Submission
The following coding submission guides were developed by the
AUC Medical Code TAG and approved by the AUC Operations
Committee. This information is found in the 5010 version of the
837P MN Companion Guide, Table A.5.1, Chapter 12.
The Health Care Home Payment Methodology Steering
Committee has determined that five levels of patient complexity
should be recognized for health care home payment purposes. In
addition, the complexity level determination must take into
account two supplemental factors (non-English speaking, and
major active mental health condition). In order to achieve the goals
of reporting five levels of patient complexity, as well as two
additional supplemental complexity factors, additional qualifiers
(modifiers or condition codes) are needed.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
11-55