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

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

Behavioral health
Policy name	Policy applies to	Effective date	Policy number
Collaborative Care Codes	Commercial & Medicare Advantage	3/2025	100

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

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

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

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