Clinical Payment and Coding Policies

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 NumberPosted

Anesthesia Clinical Payment and Coding Information 

 CPCP010  4/2/18

Applied Behavior Analysis for Autism Spectrum Disorders 

 CPCP011  5/21/18

Chiropractic Services 

 CPCP016  5/21/18

Co-Surgeon/Team Surgeon Modifiers 

 CPCP009  4/2/18
E&M of ER Coding   CPCP003  5/21/18

Global Surgical Package 

 CPCP014  4/2/18

Hernia Repair 

 CPCP012  4/2/18

Implant Policy 

 CPCP007  4/2/18

Increased Procedural Services (modifier 22) 

 CPCP013  4/2/18
Inpatient/Outpatient Unbundling   CPCP002  5/21/18

Multiple Procedures 

 CPCP015  4/2/18
 

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

Reimbursement

 

CPCP004

 

 5/21/18

Observation Services   CPCP001  4/2/18
Preventive Services   CPCP006  5/14/18
Psychological and Neuropsychological Testing  CPCP008  9/5/17