Clinical Payment and Coding Policies
This information does not apply to members who have Medicaid or Medicare plans.
Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.
Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.
In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.
In the event of conflict between a Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides services to eligible member(s) and/or plans, the provider contract will govern.
View the current policies below:
|Policy Name||Policy Number & Version||Effective Date|
|Coordinated Home Care/Private Duty Nursing||CPCP05 v.6.0||12/1/2019|
|Corrected Claim Submissions||CPCP25 v.6.0||12/1/2019|
|Evaluation and Management (E/M) Services Coding – Facility Services||CPCP003 v.4.0||1/1/2020|
|Evaluation and Management (E/M) Coding – Professional Provider Services||CPCP024 v.5.0||1/1/2020|
|Inpatient/Outpatient Unbundling Policy||CPCP002 v.4.0||6/1/2019|
|Observation Services Tool for Applying MCG Care Guidelines Clinical Payment and Coding Policy||CPCP001 v.4.0||6/1/2019|