Reimbursement Methodology for Non-Participating Providers

Policy No: 135
Originally Created: 01/01/2018
Section: Administrative
Last Reviewed: 11/01/2018
Last Revised: 11/01/2018
Approved: 11/15/2018
Effective: 01/01/2019

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.

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
    • ClaimsXten™ Unbundled Code Pairs
    • Incidental Unlisted Codes
  • Clinical Edits which may include, but are not limited to the following:
    • Non-Reimbursable Services
    • Unlisted Code Review
    • Investigational Denials
    • Not Medically Necessary Denials
    • Cosmetic Denials
    • 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) or Discounting
      • Bilateral Pricing
      • Assistant Surgeon Pricing
      • Co-Surgeon, Team Surgeon Pricing
  • Average Ambulatory Payment Classifications (APC) Outpatient Prospective Payment System (OPPS) Fee Schedule Payment Rules used for outpatient hospital procedures including, but are not limited to:
    • Procedure Code OPPS Payment Status Indicators (SI)
    • Procedure Codes that are Device Intensive (OPPS) includes the Implant or Device
    • Non-reimbursable Procedure Codes
      • Procedure Codes Not paid under OPPS, except specific additional procedure codes the plan has determined to be allowable in a hospital setting.
      • OPPS Procedure Codes Packaged Service/item
      • Outpatient Code Editor (OCE) edits applicable to non-Medicare products.
  • Average ASC Fee Schedule Payment Rules, including, but are not limited to:
    • Definition of an ASC
    • ASC payment rules
      • Billing on Centers for Medicare & Medicaid Services (CMS) 1500 equivalent
      • ICD-10 coding
      • Multiple Procedure pricing
      • Modifier Pricing
      • Bilateral Procedures billed according to CMS Guidelines
      • Discontinued Procedures
      • All Inclusive Rate with no separate payment for any other service, supply, implant or device; not specifically identified as separately allowable.
    • Procedure Code Payment Indicators (PI)
    • Procedure Codes that are Device Intensive (ASC) includes the Implant or Device
    • Non-reimbursable Procedure Codes
      • Procedure Codes excluded from Payment in an ASC, except procedure codes the plan has additionally determined to be allowable in an ASC
    • ASC Procedure Codes Packaged Service/item
  • Average APC Outpatient Prospective Payment System (OPPS) and ASC-OPPS Fee Schedule Payment Rules used for ASC allowable procedures, including, but are not limited to:
    • Procedure Code in APC-OPPS and ASC-OPPS Payment Status Indicators (PSI)
    • Procedure Codes that are Device Inclusive (OPPS) includes the Implant or Device
    • Non-reimbursable Procedure Codes
      • Procedure Codes Not paid under OPPS, except specific additional procedure codes the plan has determined to be allowable in an ASC.
    • ASC-OPPS Procedure Codes Packaged Services
  • ClaimsXtenTM Rules
  • Medically Unlikely Edits (MUEs)
  • Inclusive Facility Fee Services (i.e., ASCs)
  • Correct Coding Validation Audits
  • Medical Policies, Reimbursement Policies and Administrative Manual

References

Current Procedural Terminology (CPT®), American Medical Association

National Ambulatory Surgical Center Fee Schedule, Calendar Year 2018/2019, Centers for Medicare & Medicaid Services (CMS)

National Physician Fee Schedule Relative Value File Calendar Year 2018/2019, 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.