Drug Testing Payment Policy Updates: CPP 166

WellCare is implementing the following policy for Drug Testing (Kentucky Medicaid) with an effective date as of 07/01/2020.

Summary of Policy

EFFECTIVE July 1, 2020: The Department for Medicaid Services (DMS) has established guidelines for the appropriate use of urine drug testing (UDT) to be used in the outpatient care of adults. This update includes changes recently enacted by the Kentucky Department for Medicaid Services.

What does this mean for providers? 

Drug testing should be individualized based on the specific patient’s clinical needs.  Evidence-based practice suggests adherence is best measured through random testing. The clinical practice of routine drug testing that occurs in circumstances such as occurring at every clinic visit or in the context of a set schedule is not preferred. The number of UDTs ordered will be monitored by provider type and place of service.  These guidelines apply to beneficiaries enrolled in managed care organizations (MCOs) and fee for service (FFS).

Providers should document the following:

1. The rationale for each UDT ordered
2. The result of the UDT
3. The clinical decision made based on the UDT result

The chart below represents the number of UDTs allowed per calendar year, per individual beneficiary.  Medical records will be required after the limit has been met.  No limits on specific codes shall be applied within each grouping, presumptive or definitive.

Presumptive and definitive UDTs done on the same date of service is allowed within the set limits. DMS and/or MCOs may require a retrospective review of UDTs.

Limits do not apply to UDT done in the Emergency Department or while the beneficiary is in any inpatient facility.

Appeals Process

If denied, beneficiaries and/or providers may appeal to WellCare per federal and state appeal statutes and regulations. 

Providers can review the complete policy at the Provider page, select Kentucky, select Claims, and then select Payment Policy.

We are here to help. Please contact your Network Representative for general inquiries regarding this program.