Reimbursement Policy

The purpose of our Reimbursement Policy Manual is to document the sources and principles used in writing our Reimbursement Policies. This information is to be used as a general reference resource regarding our Reimbursement Policies and not intended to address every aspect of a reimbursement situation. Reasonable discretion may be used in applying our Reimbursement Policies to individual situations.

The following nationally recognized sources are consulted in the development of our health plan Reimbursement Policies.

Centers for Medicare & Medicaid Services (CMS) written policy
CMS Local Carrier and National Carrier Determinations (LCD NCD)
CMS Manuals and Publications
CPT Assistant
CPT Manual, including code definitions and associated text
Federal Register
HCPCS Manual, including code definitions and associated text
Integrated Outpatient Code Editor (I/OCE)
International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) official guidelines for coding and reporting
International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) official guidelines for coding and reporting
Medically Unlikely Edits
National Correct Coding Policy Manual for Part B Medicare Carriers (NCCI)
National Physician Fee Schedule Relative Value File

Comments from physicians and other health care professionals regarding reimbursement policies are welcome.

If you have a comment regarding a reimbursement policy, please contact the Provider Contact Center.

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

Administrative
Policy name	Effective date	Policy number
Allergy Immunotherapy	11/2023	100
Ambulance Guidelines	4/2024	121
Associated Claims	3/2024	119
Bundling Edits	11/2023	105
Care Management Services	1/2024	122
Chiropractic and Osteopathic Treatments	3/2024	138
Correct Coding Guidelines	8/2023	129
Custom Oral Appliances	9/2023	102
Diabetic Supplies	1/2024	128
Dialysis Services for ESRD	2/2024	141
DME Purchase and Rental Limitations and Reimbursement	12/2023	131
Global Days – Current policy Global Days – Effective 8/1/2024	9/2023	101
Implants, Implant Components, Medical and Surgical Supplies for all Surgical Procedures	1/2024	125
Incident to Services	1/2024	148
Incidental Procedures	5/2024	108
Injection and Infusion Services	11/2023	109
Inpatient Hospital Readmissions	1/2024	111
Intensity Modulated Radiotherapy (IMRT) Bundling	9/2023	110
Intermittent Catheter Supplies	3/2024	149
Maximum Daily Units	5/2024	120
Medicare-Based Fee Effective Dates	11/2023	114
Non-Reimbursable Services	4/2024	107
Palliative Care	12/2023	136
Physician Concierge Services	6/2023	130
Pneumatic Compression Device	5/2024	134
Positive Airway Pressure (PAP) Supplies	4/2024	127
Preventable Adverse Events	6/2023	106
Preventive Medicine Evaluation and Management Visits	11/2023	133
Pricing Codes Without RVUs	8/2023	113
Reimbursement Methodology for Non-Participating Providers	1/2024	135
Timely Receipt of Medical Records	1/2024	145
Transportation of Portable X-Ray Equipment	1/2024	147
Virtual Care – Current policy Virtual Care – Effective 8/1/2024 View information about telehealth services.	1/2024	132

Anesthesia
Policy name	Effective date	Policy number
Anesthesia Reimbursement & Services Reporting – Group and Individual – Current policy Anesthesia Reimbursement & Services Reporting – Group and Individual – Effective 8/1/2024	4/2023	102

Behavioral health
Policy name	Effective date	Policy number
Collaborative Care Codes	3/2024	100

Facility
Policy name	Effective date	Policy number
Critical Care and Trauma Activation	5/2023	118
Emergency Department Visits – Level of Service	1/2024	110
Facility DRG Validation	3/2024	111
Inpatient Medications Reimbursed Under Medical Coverage	3/2024	116
Reimbursement of Chest X-Rays and Radiologic Guidance for Facilities	5/2024	105
Reimbursement of Facility Room and Board	1/2024	103
Reimbursement of IV Solutions, Premixed IV Medications, Epidural, Intra-arterial and Intrathecal Solutions and TPN for Facilities	1/2024	109
Reimbursement of Respiratory Therapy Services for Facilities	2/2024	108

Medicine
Policy name	Effective date	Policy number
Blood Processing	12/2023	110
Cellular and Gene Therapy Products	2/2024	112
Discarded Drugs and Biologicals	9/2023	108
Drugs, Immunizations/Vaccines, Radiopharmaceuticals, and Skin Substitutes Reimbursed Under Medical Coverage	1/2024	104
Maternity Care - current policy Maternity Care - effective 6/1/2024	1/2023	107
New Patient Visit	5/2024	101
Urine Drug Testing	9/2023	106

Modifiers
Policy name	Effective date	Policy number
Modifier 22; Increased Procedural Services	1/2024	111
Modifier 25; Significant, Separately Identifiable E&M Service	7/2023	103
Modifier 26; Professional Component Modifier TC; Technical Component	8/2023	106
Modifier 50; Bilateral Procedure	8/2023	108
Modifier 51 and Multiple Procedure Logic	5/2023	101
Modifier 52; Reduced Services	4/2024	115
Modifier 53; Discontinued Procedure	7/2023	102
Modifier 54; Surgical Care Only; Modifier 55; Postoperative Management Only; Modifier 56; Preoperative Management Only	5/2024	107
Modifier 57; Decision for Surgery	5/2023	104
Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service	8/2023	105
Modifier 62; Two Surgeons/Co-Surgeons	8/2023	113
Modifier 63; Procedure Performed on Infants Less than 4 kg	3/2024	110
Modifier 66; Surgical Team	7/2023	114
Modifiers 73 and 74; Discontinued Services	12/2023	116
Modifier 78; Unplanned Return to the Operating/Procedure Room By the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period	5/2023	112
Modifiers 80, 81, 82, AS; Assistant at Surgery	9/2023	109
Modifier 90; Reference (Outside) Laboratory	4/2024	118

Surgery
Policy name	Effective date	Policy number
Frenotomy	4/2024	102
Hiatal Hernia Repair - Gastropexy When Performed With Major Surgical Procedures	3/2024	104
Intraoperative Monitoring	4/2024	101

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.