Reimbursement Methodology for Non-Participating Providers

Policy No: 135
Originally Created: 01/01/2018
Section: Administrative
Last Reviewed: 09/01/2021
Last Revised: 09/01/2021
Approved: 09/09/2021
Effective: 01/01/2022

This policy applies to Non-Participating outpatient hospitals, ambulatory surgical centers (ASCs), birth centers, outpatient behavioral health treatment facilities, independent laboratories, physicians and other qualified health care professionals.

Note: Certain NonPar payment methodologies are not applicable to Medicare Advantage claims.

Definitions

Non-Participating (NonPar) Provider
A provider who has not entered into a contractual agreement with our health plan for the member's product. Also referred to as Out-of-Network Provider.

(See Policy Cross References for additional definitions)

Policy statement

Claims submitted by NonPar providers will be processed according to the NonPar payment methodology in place at the time of service. Claims may be subject to, but are not limited to, the following:

  • Bundled services which may include the application of, but are not limited to:
    • National Correct Coding Initiative (NCCI)
    • Correct Code Editor (CCE) Code Pairs (Not applicable to Medicare Advantage)
    • ClaimsXten™ Unbundled Code Pairs (Not applicable to Medicare Advantage)
    • Incidental Unlisted Codes
  • Clinical Edits which may include, but are not limited to the following:
    • Non-Reimbursable Services
    • Unlisted Code Review
    • Investigational Denials (Not applicable to Medicare Advantage)
    • Not Medically Necessary Denials
    • Cosmetic Denials (Not applicable to Medicare Advantage)
    • Benefit Denials
  • National Physician Fee Schedule Relative Value File pricing rules, including, but are not limited to:
    • Procedure Code Status Indicators
    • Global Periods
    • Modifier Pricing, including:
      • Professional/Technical Component
      • Multiple Service Reduction (MSR)
      • Multiple Procedure Pricing Reduction (MPPR) (Applicable to Medicare Advantage)
      • Bilateral Pricing
      • Assistant Surgeon Pricing
      • Co-Surgeon, Team Surgeon Pricing
  • Freestanding ASC payment methodology is based on Centers for Medicare & Medicaid Services (CMS) ASC payment system, as well as CMS Outpatient Prospective Payment System (OPPS) with our Company modifications.
  • Outpatient Hospital payment methodology is based on CMS Outpatient Prospective Payment System (OPPS)
  • ClaimsXtenTM Rules
  • Medically Unlikely Edits (MUEs)
  • Integrated Outpatient Code Editor (I/OCE) Clinical edits
  • Inclusive Facility Fee Services (i.e., ASCs)
  • Correct Coding Validation Audits
  • Medical Policies, Reimbursement Policies and Administrative Manual
  • Reimbursement at the lesser of billed charges or the NonPar reimbursement methodology allowed amount

References

Centers for Medicare & Medicaid Services (CMS), OCE Purpose

Centers for Medicare & Medicaid Services (CMS), Pub 100-04 Medicare Claims Processing

Current Procedural Terminology (CPT®), American Medical Association

National Ambulatory Surgical Center Fee Schedule, Calendar Year 2020, Centers for Medicare & Medicaid Services (CMS)

National Physician Fee Schedule Relative Value File Calendar Year 2020, Centers for Medicare & Medicaid Services (CMS)

NCCI Policy Manual for Medicare Services, current version, Chapter 1, General Correct Coding Policies

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.