Medical Evaluations and Diagnostic Procedures

Medical Evidence Fee Schedule

Revised On: January 1, 2023

Medical Evaluations and Diagnostic Procedures

You must be enrolled in ProviderOne to claim reimbursement for these services. Please visit the Health Care Authority’s New Providers page for information about ProviderOne enrollment.

NOTE: We only pay for non-invasive diagnostic services and exams necessary to establish a diagnosis or the severity of an impairment that limits work activity. We reimburse for the costs of obtaining the objective evidence necessary to determine disability based on our published fee schedule and established Medicaid rates.

For services not included on this fee schedule, you may need to submit a separate claim to ProviderOne using established CPT codes.

The maximum payment for all evaluation and report services includes the cost of providing chart notes and medical records.

Reimbursement Fee Table
Service Type ⃰	Reimbursement Fee	ProviderOne Service Code
General physical evaluation	$180.00	99455
Comprehensive physical evaluation	$200.00	99456
Report from records	$31.00	99080
Missed appointment	$30.00	99199
Non-Invasive Diagnostic Testing	Established Medicaid Rates	Established CPT Codes

⃰ This section details Aged, Blind, or Disabled (ABD) program medical evidence reimbursement rates. For a detailed service descriptions visit the Medical Evidence Reimbursements section of the ESA Social Services Manual.