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

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Policy name	Effective date	Policy applies to	Policy number
Allergy Immunotherapy	11/2024	Commercia	100
Ambulance Guidelines	4/2025	Commercial & Medicare Advantage	121
Ambulance Guidelines – Medicare Advantage	4/2025	Medicare Advantage	121
Associated Claims	3/2025	Commercial & Medicare Advantage	119

Administrative
Policy name	Effective date	Policy number	Commercial	Commercial and Medicare Advantage	Medicare Advantage
Allergy Immunotherapy	11/2024	100	yes
Ambulance Guidelines	4/2025	121	yes
Ambulance Guidelines – Medicare Advantage	4/2025	121			yes
Associated Claims	3/2025	119		yes

Administrative
Policy name	Effective date	Policy number
Allergy Immunotherapy – Commercial	11/2024	100
Ambulance Guidelines – Commercial Ambulance Guidelines – Medicare Advantage	4/2025	121
Associated Claims – Commercial and Medicare Advantage	3/2025	119
Bundling Edits – Commercial and Medicare Advantage	12/2024	105
Care Management Services – Commercial and Medicare Advantage	12/2024	122
Chiropractic and Osteopathic Treatments – Commercial Chiropractic and Osteopathic Treatments – Medicare Advantage	3/2025	138
Compression Garments for Lymphedema – Medicare Advantage	6/2025	150
Correct Coding Guidelines – Commercial and Medicare Advantage	8/2024	129
Custom Oral Appliances – Commercial and Medicare Advantage	9/2024	102
Diabetic Supplies – Commercial Diabetic Supplies – Medicare Advantage	12/2024	128
Dialysis Services for ESRD – Commercial and Medicare Advantage	2/2025	141
DME Purchase and Rental Limitations and Reimbursement – Commercial DME Purchase and Rental Limitations and Reimbursement – Medicare Advantage	12/2024	131
Global Days – Commercial and Medicare Advantage	8/2024	101
Hearing Aid Supplies – Commercial	1/1/2024	152
Implants, Implant Components, Medical and Surgical Supplies for all Surgical Procedures – Commercial and Medicare Advantage	1/2025	125
Incident to Services – Commercial	1/2025	148
Incidental Procedures – Commercial and Medicare Advantage	5/2025	108
Injection and Infusion Services – Commercial and Medicare Advantage	11/2024	109
Inpatient Hospital Readmissions – Commercial Inpatient Hospital Readmissions – Medicare Advantage	9/2024	111
Intensity Modulated Radiotherapy (IMRT) Bundling – Commercial and Medicare Advantage	9/2024	110
Intermittent Catheter Supplies – Commercial and Medicare Advantage	3/2025	149
Maximum Daily Units – Commercial and Medicare Advantage	5/2025	120
Medicare-Based Fee Effective Dates – Commercial Medicare-Based Fee Effective Dates – Medicare Advantage	9/2024	114
Non-Reimbursable Services – Commercial and Medicare Advantage	4/2025	107
Palliative Care – Commercial Palliative Care – Medicare Advantage	1/2025	136
Physician Concierge Services – Commercial and Medicare Advantage	9/2024	130
Pneumatic Compression Device – Commercial Pneumatic Compression Device – Medicare Advantage	5/2025	134
Positive Airway Pressure (PAP) Supplies – Commercial and Medicare Advantage	4/2025	127
Preventable Adverse Events – Commercial Preventable Adverse Events – Medicare Advantage	6/2025	106
Preventive Medicine Evaluation and Management Visits – Commercial	11/2024	133
Pricing Codes Without RVUs – Commercial Pricing Codes Without RVUs – Medicare Advantage	9/2024	113
Radiation Oncology – Commercial and Medicare Advantage	11/2024	151
Reimbursement Methodology for Non-Participating Providers – Commercial and Medicare Advantage	1/2025	135
Timely Receipt of Medical Records – Commercial and Medicare Advantage	1/2025	145
Transportation of Portable X-Ray Equipment – Commercial and Medicare Advantage	1/2025	147
Virtual Care – Commercial Virtual Care – Medicare Advantage View information about telehealth services.	5/2025	132

Anesthesia
Policy name	Effective date	Policy number
Anesthesia Reimbursement & Services Reporting – Commercial Anesthesia Reimbursement & Services Reporting – Medicare Advantage	11/2024	102

Behavioral health
Policy name	Effective date	Policy number
Collaborative Care Codes – Commercial and Medicare Advantage	3/2025	100

Facility
Policy name	Effective date	Policy number
Critical Care and Trauma Activation – Commercial and Medicare Advantage	6/2025	118
Drug Discount Programs – Acquired and Biologicals – Medicare Advantage	5/2025	114
Emergency Department Visits – Level of Service – Commercial and Medicare Advantage	11/2024	110
Facility DRG Validation – Commercial and Medicare Advantage	3/2025	111
Inpatient Medications Reimbursed Under Medical Coverage – Commercial and Medicare Advantage	3/2025	116
Reimbursement of Chest X-Rays and Radiologic Guidance for Facilities – Commercial and Medicare Advantage	5/2025	105
Reimbursement of Facility Room and Board – Commercial and Medicare Advantage	1/2025	103
Reimbursement of Hospital Compound Solutions – Commercial and Medicare Advantage	5/2025	109
Reimbursement of Respiratory Therapy Services for Facilities – Commercial and Medicare Advantage	2/2025	108
Sepsis – Commercial and Medicare Advantage – New policy - effective 7/1/2025	7/2025	120

Medicine
Policy name	Effective date	Policy number
Blood Processing – Commercial and Medicare Advantage	11/2024	110
Cellular and Gene Therapy Products – Commercial and Medicare Advantage	3/2025	112
Discarded Drugs and Biologicals – Commercial and Medicare Advantage	9/2024	108
Drugs, Immunizations/Vaccines, Radiopharmaceuticals, and Skin Substitutes Reimbursed Under Medical Coverage – Commercial Drugs, Immunizations/Vaccines, Radiopharmaceuticals, and Skin Substitutes Reimbursed Under Medical Coverage – Medicare Advantage	6/2025	104
Maternity Care – Commercial and Medicare Advantage	3/2025	107
New Patient Visit – Commercial and Medicare Advantage	5/2025	101
Urine Drug Testing – Commercial Urine Drug Testing - Medicare Advantage	9/2024	106

Modifiers
Policy name	Effective date	Policy number
Modifier 22; Increased Procedural Services – Commercial and Medicare Advantage	1/2024	111
Modifier 25; Significant, Separately Identifiable E&M Service – Commercial and Medicare Advantage	7/2023	103
Modifier 26; Professional Component Modifier TC; Technical Component – Commercial and Medicare Advantage	10/2024	106
Modifier 50; Bilateral Procedure – Commercial Modifier 50; Bilateral Procedure – Medicare Advantage	8/2024	108
Modifier 51 and Multiple Procedure Logic – Commercial Modifier 51 and Multiple Procedure Logic – Medicare Advantage	11/2024	101
Modifier 52; Reduced Services – Commercial and Medicare Advantage	4/2025	115
Modifier 53; Discontinued Procedure – Commercial and Medicare Advantage	8/2024	102
Modifier 54; Surgical Care Only; Modifier 55; Postoperative Management Only; Modifier 56; Preoperative Management Only – Commercial and Medicare Advantage	5/2025	107
Modifier 57; Decision for Surgery – Commercial and Medicare Advantage	7/2024	104
Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service – Commercial and Medicare Advantage	8/2024	105
Modifier 62; Two Surgeons/Co-Surgeons – Commercial and Medicare Advantage	8/2024	113
Modifier 63; Procedure Performed on Infants Less than 4 kg – Commercial	3/2025	110
Modifier 66; Surgical Team – Commercial and Medicare Advantage	7/2024	114
Modifiers 73 and 74; Discontinued Services – Commercial and Medicare Advantage	12/2024	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 – Commercial and Medicare Advantage	7/2024	112
Modifiers 80, 81, 82, AS; Assistant at Surgery – Commercial Modifiers 80, 81, 82, AS; Assistant at Surgery – Medicare Advantage	9/2024	109
Modifier 90; Reference (Outside) Laboratory – Commercial and Medicare Advantage	4/2025	118

Surgery
Policy name	Effective date	Policy number
Frenotomy – Commercial and Medicare Advantage	4/2025	102
Hiatal Hernia Repair - Gastropexy When Performed With Major Surgical Procedures – Commercial and Medicare Advantage	3/2025	104
Intraoperative Monitoring – Commercial and Medicare Advantage	4/2025	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.