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.3.0  9/13/2021

Applied Behavior Analysis 

CPCP011 v.3.0  11/25/2020

Chiropractic Services 

CPCP016 v.1.0  9/25/2020
Coordinated Home Care/Private Duty Nursing CPCP05 v.1.0  9/25/2020
Corrected Claim Submissions CPCP25 v.2.0  5/1/2020

Co-Surgeon/Team Surgeon Modifiers 

CPCP009 v.1.0  10/5/2021

Drug Testing Clinical Payment and Coding Policy

CPCP20 v.2.0  9/4/2020
Evaluation and Management (E/M) Services Coding – Facility Services   CPCP003 v.1.0  11/6/2020
Evaluation and Management (E/M) Coding – Professional Provider Services CPCP024 v.3.0  12/7/2020

Global Surgical Package 

CPCP014 v.1.0  5/11/2021

Hernia Repair 

CPCP012 v.2.0  6/18/2021

Home Infusion

CPCP019 v.3.0  9/7/2021

Implant Payment and Coding Policy 

CPCP007 v.1.0  7/6/2020

Increased Procedural Services (Modifier 22) 

CPCP013 v.2.0  5/1/2021
Inpatient Readmissions  CPCP027 v.2.0  3/1/2020
Inpatient/Outpatient Unbundling Policy  CPCP002 v.1.0  12/4/2020
Intraoperative Neurophysiology Monitoring Coding and Reimbursement Guideline  CPCP032 v.3.0  7/30/2021

Laboratory Management Program

CPCP037v1.0  12/1/2021

Laboratory Panel Billing Guideline

CPCP021 v.2.0  7/30/2021

Medical Record Documentation Guidelines 

CPCP029 v.5.0  9/22/2021

Modifier Reference Guideline 

CPCP023 v.2.0  4/1/2021

Multiple Surgical Procedures 

CPCP015 v.1.0  8/24/2021

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

CPCP004 v.1.0


Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

CPCP028 v.1.0  5/15/2021

Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU)

CPCP028 v.2.0  8/15/2021
Observation Services Tool for Applying MCG Care Guidelines Clinical Payment and Coding Policy  CPCP001 v.2.0  7/20/2021

Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes

CPCP018 v.2.0  10/30/2020

Paravertebral Facet Injection Procedure Coding & Billing Policy

CPCP036 v.7.0  10/14/2021

Pneumatic Compression Devices 

CPCP022 v.2.0  9/1/2020

Point-of-Care Ultrasound Examination Guideline

CPCP030 v.1.0  6/4/2021

Preventive Services Policy 

CPCP006 v.1.0  10/1/2021

Psychological and Neuropsychological Testing

CPCP008 v.1.0  4/1/2021

Trauma Activation - Facility Services 

CPCP031 v.1.0  5/11/2021

Unbundling Professional 

CPCP034 v.2.0  8/4/2021

Wasted/Discarded Drugs and Biologicals Guideline

CPCP017 v.3.0  9/11/2020