This update is effective June 30, 2026, to support accurate coding and billing practices and guidelines
We are implementing a new claims payment edit, effective June 30, 2026. This edit reinforces appropriate billing of comprehensive (inclusive) procedure codes when applicable.
Unbundled treatment codes
If a service is already included in a more comprehensive (inclusive or parent) procedure code, it should not be billed separately. When both are billed, the component code will be denied because it is bundled into the primary service.
This coding edit identifies incorrect coding based on the scenarios outlined below.
- Applies to: Mental health and substance use disorder providers.
Unbundling claims scenarios subject to denial
Claims are evaluated using a seven calendar day lookback for the same patient and the same physician, practitioner or other provider.
- Scenario 1: A claim billed with 80305, 80306, 80307, G0480, G0481, G0482 or G0483 will be denied if another claim has already been submitted or paid for G2067, G2068, G2069, G2073, G2074 or G2075 within seven calendar days for the same patient and same physician, practitioner or other provider.
- Scenario 2: A claim billed with G2067, G2068, G2069, G2073, G2074 or G2075 will be denied if another claim has already been submitted or paid for 80305, 80306, 80307, G0480, G0481, G0482 or G0483 within seven calendar days for the same patient and same physician.
How to avoid denials and processing delays
When submitting a claim:
- Confirm the member’s patient status.
- Use established patient CPT codes when applicable.
- Report the inclusive or parent code when one code fully describes the service provided.
- Do not separate bill component services that are integral to the primary procedure. Billing both the comprehensive code and its components may result in denial of the component code.
- Only bill separate services when documentation supports a distinct, separately identifiable service and when allowed under applicable coding guidelines.
Payment policies: Billing guidance and access
Payment policies are published to help you understand acceptable billing practices and reimbursement methodologies for certain procedures and services. These policies are applied as claims reimbursement edits within the claims adjudication system, in addition to other reimbursement processes currently in place.
What payment policies address
- Coding inaccuracies
- Diagnosis-to-procedure code mismatches
- Inappropriately modified procedures
- Unbundling
- Incidental procedures
- Duplicate services
- Health plan-specific payment rules
Policy standards and references
Payment policies are based on medical literature, research and industry standards, including guidance from:
- American Medical Association Current Procedural Terminology (CPT®)
- Centers for Medicare & Medicaid Services
- Publicly available specialty society guidance
Unless otherwise specified, policies align with applicable California fee-for-service provider manuals and regulations.
CPT codes referenced in payment policies may not be all-inclusive and are subject to change.
Access Payment Policies
Payment policies are available at https://bit.ly/Wellcare-Payment-Policies.
Need help? Contact us
If you have questions regarding the information contained in this update, contact 1-866-999-3945.
