QUEST Integration - Anesthesia

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

Anesthesia is covered when:

• The procedure requires anesthesia
• The procedure is covered (e.g., not cosmetic, not investigational, etc.)
• The type of anesthesia is covered

Anesthesia services may be billed by any Medicaid-contracted Anesthesiologist, CRNA or specialist who has these sub-specialties.

Referral Requirement

Anesthesia for medical surgical procedures does not require referral by the patient's PCP.

If a patient is undergoing dental procedures under general anesthesia, services are covered under the patient's QUEST Integration medical plan. Please check with the patient's QUEST Integration medical plan for plan requirements. If the member is part of HMSA's Medical Plan for QUEST Integration Members, the doctor doing the dental procedure must obtain precertification for the dental service and provide documentation that a referral from the patient's PCP for the hospitalization and anesthesia also was obtained.

Precertification Requirement

Approval of a procedure that requires precertification includes anesthesia services when the procedure is authorized. A copy of a valid signed Sterilization Consent Form 1146 should also be attached to claims for anesthesia services related to those procedures.

Claims Filing Information

Please enter the appropriate anesthesia procedure code in Block 24D of the HCFA 1500 claim form. The total anesthesia time in minutes only must be reported in column 24G.

HMSA's QUEST Integration Plan uses Medicare's base unit values for anesthesia services.

Note: The claim must contain documentation to explain any anesthesia risk.

Nurse Anesthetist Services

Nurse anesthetist services are covered.

Anesthesia for Long Labor

Payment of anesthesia services provided during labor is made according to the unit values listed below, which represent a combination of the base units for anesthesia rendered during labor, and time units.

For each additional hour beyond three, one more unit will be allowed. Thus four hours would be valued at 14 units, five hours at 15 units, six hours at 16 units and so on. A maximum number of units will not be imposed as long as services are being rendered.

Anesthesia Eligible Charge Formula

[(Base Units x 15) + Minutes] x (Conversion Factor Rate ÷ 15) = Eligible Charge
Note: Rounding may affect the Eligible amount.

Revision History