Urine Drug Testing Benefit Change

he Oregon Health Plan (OHP) made coverage changes to drug testing that took effect on 10/1/18. Health Share, Jackson Care Connect, Columbia Pacific CC and CareOregon will comply with these changes effective 3/1/19. 

As of that date, confirmatory urine drug testing codes G0481-G0483 are no longer covered on the Prioritized List and are no longer eligible for payment.  CareOregon will also be adhering to the benefit limits on CPT codes 80305-80307 and HCPCS code G0480, in accordance to the criteria determined by OHP.

Presumptive drug testing is covered (with annual limits) and should be ordered only when the results will affect treatment planning, such as for patients receiving treatment for a substance use disorder.

Confirmatory drug testing is only medically indicated when the result of presumptive testing is inconsistent with the clinical situation and the results would change management, or in those cases where presumptive testing is known to be inadequate in detecting certain substances.

In the case of members undergoing treatment for a substance use disorder, annual limits for testing are 36 presumptive tests and 12 confirmatory tests.  These are the coverage limits for all conditions/members other than as noted below.

Annual limits for presumptive drug testing for members receiving chronic opioid therapy vary depending on risk assessed by a validated opioid risk assessment tool.  Limits are:

•           Low Risk:  Random presumptive testing up to 2x/year

•           Moderate Risk:  Random presumptive testing up to 4x/year

•           High Risk:  Random presumptive testing up to 12x/year

Definitive testing should only occur for confirmatory purposes as described above, and in no case, should this exceed 12 tests/year.

When confirmatory testing is performed, only HCPCS code G0480 will be covered.  As of 3/1/19 we will no longer cover codes G0481-G0483 for definitive testing. 

Please refer to the OHA notifications below for full details on these changes.

https://www.oregon.gov/oha/HPA/DSI-HERC/EvidenceBasedReports/Prioritization%20Changes%20UDT.pdf

With Regards,

Douglas Luther, MD

Senior Medical Director, CareOregon/JCC/CPCCO

Click here to download this letter for your records.