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

11/2023

100

4/2023

121

3/2023

119

11/2023

105

1/2024

122

11/2022

138

8/2023

129

9/2023

102

1/2024

128

2/2024

141

12/2023

131

9/2023

101

1/2024

125

4/2023

148

5/2023

108

11/2023

109

1/2024

111

9/2023

110

Intermittent Catheter Suppliesnew policy effective 3/1/2024

3/2024

149

5/2023

120

11/2023

114

4/2023

107

12/2023

136

6/2023

130

5/2023

134

4/2023

127

6/2023

106

11/2023

133

8/2023

113

1/2024

135

1/2024

145

1/2024

147

Virtual Care

View information about telehealth services.

10/2023

132

Anesthesia

Policy name

Effective date

Policy number

4/2023

102

Behavioral health

Policy name

Effective date

Policy number

3/2023

100

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.