The Reimbursement Policy Manual is intended only for physicians and other health care professionals, except where otherwise indicated.
By clicking "I Accept" below, you acknowledge your understanding and agreement with the following:
This Reimbursement Policy Manual documents payment methodology for medical and surgical services and supplies. THIS REIMBURSEMENT POLICY DOES NOT APPLY TO ANY OTHER COMPANY.
Reimbursement Policy is used by the Company to provide consistent and predictable claims payment.
Reimbursement Policy facilitates the systematic application of our member contracts, provider contracts, and medical policies. These documents will govern in the event of a conflict with the Reimbursement Policy. In the event that such contracts and policies are silent, we may choose to defer to Center for Medicare & Medicaid Services (CMS) guidance when applicable.
- We will implement quarterly updates to Correct Coding Editor (CCE), CMS sourced edits and Lyric sourced edits within 30 days of their effective date retro-active to the 1st day of the quarter. Claims received before our systems are updated will not be adjusted. (For National Coverage Determination (NCD)/Local Coverage Determination (LCD) updates please see Coding Toolkit).
- Reimbursement Policy shall be interpreted and modified in the sole discretion of the Company.
- Reimbursement Policy does not determine the schedule of benefits. Rather, Reimbursement Policy supports the schedule of benefits by establishing payment rules, coding hierarchy and related processing systems' edits.
- Health care facilities, physicians and other health care providers are expected to exercise their medical judgment in providing the most appropriate care. Reimbursement policy is not intended to dictate medical practice and does not constitute medical advice. However, the information which is provided to the plan must be accurate, complete, and truthful.
- Reimbursement Policy is the property of the Company and you are strictly prohibited from using it for any commercial use whatsoever. Commercial use does not include use of the Reimbursement Policy related to benefit payment for health care services received by one of our members.
- Current Procedural Terminology CPT® codes and descriptions are the property of the American Medical Association with all rights reserved. You are strictly prohibited from using CPT® codes for any unauthorized use whatsoever.
- The coding software guidelines are incorporated into the Reimbursement Policy by reference. Thus, to the extent there are situations not documented in the Reimbursement Policy, coding software guidelines control.
- Reimbursement Policy may be revised from time to time. The Company will provide ninety (90) days written notice of Reimbursement Policy or Coding Toolkit updates where we develop the editing criteria that result in a reduction to compensation.
- ClaimsXten clinical edit content that is proprietary to Lyric will be installed on an ongoing basis, without prior written notice, to support existing reimbursement policies.
- Multiplan’s payment integrity service content is proprietary and used as a secondary editor supporting our existing policies and edits.