Outpatient Hospital Billing Guide updates eff. 2/1/2020

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Apple Health (Medicaid) Provider Alert

The Health Care Authority (HCA) revised the Outpatient Hospital Services Billing Guide, dated February 1, 2020.

What has changed?


  • Pays for skin substitutes in an outpatient hospital setting if the skin substitutes have a designation of high/low on the Centers for Medicare and Medicaid Services (CMS) list MM11099.
  • Covers Zulresso™.

For specific details, see the What has changed table in the revised guide.

HCA also revised the guide to indicate that outpatient facility fees associated with dental procedures (CDT codes or CPT codes) must be billed through an HCA-contracted managed care organization (MCO) for eligible clients enrolled in an MCO.*

HCA continues to pay for the following through fee-for-service:

  • Professional fees for dental procedures using CDT codes
  • Professional fees using CPT codes only when the provider’s taxonomy starts with a 12. See the Dental-Related Services Billing Guide on how to bill professional fees.

Note: The agency will continue to determine site-of-services prior authorization for facility fees associated with dental procedure codes.


*If a client is not enrolled in an HCA-contracted MCO, bill HCA for services.