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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 & VersionEffective Date

Anesthesia Clinical Payment and Coding Information 

CPCP010 v.1.0  6/1/2019

Applied Behavior Analysis 

CPCP011 v.9.0  8/21/2018

Chiropractic Services 

CPCP016 v.7.0  9/1/2019
Coordinated Home Care/Private Duty Nursing CPCP05 v.6.0  12/1/2019
Corrected Claim Submissions CPCP25 v.6.0  12/1/2019

Co-Surgeon/Team Surgeon Modifiers 

CPCP009 v.2.0  10/1/2019
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

Global Surgical Package 

CPCP014 v.4.0  6/1/2019

Hernia Repair 

CPCP012 v.6.0  6/1/2019

Home Infusion

CPCP019 v.2.0  6/1/2019

Implant Payment and Coding Policy 

CPCP007 v.4.0  6/1/2019

Increased Procedural Services (Modifier 22) 

CPCP013 v.4.0  6/1/2019
Inpatient/Outpatient Unbundling Policy  CPCP002 v.4.0  6/1/2019

Laboratory Panel Billing Guideline

CPCP021 v.4.0  6/1/2019

Multiple Surgical Procedures 

CPCP015 v.6.0  6/1/2019

Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy

CPCP004 v.3.0

 6/1/2019

 

Observation Services Tool for Applying MCG Care Guidelines Clinical Payment and Coding Policy  CPCP001 v.4.0  6/1/2019

Pneumatic Compression Devices 

CPCP022 v.7.0  9/1/2019

Preventive Services Policy 

CPCP006 v.1.0  10/1/2019

Psychological and Neuropsychological Testing

CPCP008 v.5.0  3/1/2019

Wasted/Discarded Drugs and Biologicals Guideline

CPCP017 v.5.0  8/1/2019