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

Anesthesia Clinical Payment and Coding Information

CPCP010 v.3.0  9/13/2021

Applied Behavior Analysis

CPCP011 v.2.0  11/9/2021

Chiropractic Services

CPCP016 v.1.0  1/1/2022
Coordinated Home Care/Private Duty Nursing CPCP005 v.1.0  10/08/2021
Corrected Claim Submissions CPCP025 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

CPCP020 v.3.0  12/29/2021
Evaluation and Management (E/M) Services Coding – Facility Services CPCP003 v.1.0  12/1/2021
Evaluation and Management (E/M) Coding – Professional Provider Services CPCP024 v.3.0  12/23/2021

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.1.0  2/24/2022
Inpatient Readmissions CPCP027 v.2.0  12/1/2021
Inpatient/Outpatient Unbundling Policy CPCP002 v.1.0  12/16/2021
Intraoperative Neurophysiology Monitoring Coding and Reimbursement Guideline CPCP032 v.3.0  7/30/2021

Laboratory Panel Billing Guideline

CPCP021 v.2.0  4/06/2022

Medical Record Documentation Guidelines

CPCP029 v.5.0  9/22/2021

Modifier Reference Guideline

CPCP023 v.2.0  5/13/2022

Multiple Surgical Procedures

CPCP015 v.1.0  8/24/2021

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

CPCP004 v.2.0

 12/13/2021

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

CPCP028 v.3.0  8/1/2022

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

CPCP028 v.3.0  4/1/2022
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.1.0  12/01/2021

Paravertebral Facet Injection Procedure Coding & Billing Policy


CPCP036 v.8.0  11/2/2021

Pneumatic Compression Devices

CPCP022 v.1.0  12/10/2021

Point-of-Care Ultrasound Examination Guideline

CPCP030 v.1.0  2/24/2022

Preventive Services Policy

CPCP006 v.1.0  7/1/2022

Psychological and Neuropsychological Testing

CPCP008 v.1.0  4/1/2021

Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding

CPCP026 v.3.0  9/7/2021

Trauma Activation - Facility Services

CPCP031 v.1.0  2/24/2022

Unbundling Professional

CPCP034 v.1.0  4/5/2022

Unlisted/Not Otherwise Classified (NOC) Coding

CPCP035 v.3.0  9/21/2021

Wasted/Discarded Drugs and Biologicals Guideline

CPCP017 v.4.0  12/21/2021

 

The Laboratory Benefit Management Program launch (previously scheduled for May 1, 2022) has been POSTPONED.

Policy Name Policy Number Effective Date

Allergen Testing

CPCPLAB013

Postponed

ANA/ENA Testing

CPCPLAB011

Postponed

β-Hemolytic Streptococcus Testing

CPCPLAB053

Postponed

Biomarker Testing for Multiple Sclerosis and Related Neurologic Diseases CPCPLAB036

Postponed

Cardiac Biomarkers for Myocardial Infarction CPCPLAB046

Postponed

Cardiovascular Disease Risk Assessment

CPCPLAB020

Postponed

Celiac Disease Testing

CPCPLAB017

Postponed

Cervical Cancer Screening CPCPLAB002

Postponed

Coronavirus Testing in the Outpatient Setting CPCPLAB057

Postponed

Diagnosis of Idiopathic Environmental Intolerance

CPCPLAB023

Postponed

Diagnosis of Vaginitis including Multi-target PCR Testing

CPCPLAB059

Postponed

Diagnostic Testing of Common Sexually Transmitted Infections

CPCPLAB051

Postponed

Diagnostic Testing of Influenza

CPCPLAB033

Postponed

Diagnostic Testing of Iron Homeostasis & Metabolism

CPCPLAB008

Postponed

DNA Ploidy Cell Cycle Analysis CPCPLAB066

Postponed

Epithelial Cell Cytology in Breast Cancer Risk Assessment CPCPLAB024

Postponed

Erectile Dysfunction CPCPLAB041

Postponed

Evaluation of Dry Eyes  CPCPLAB043

Postponed

Fecal Analysis in the Diagnosis of Intestinal Dysbiosis  CPCPLAB025

Postponed

Fecal Calprotectin Testing  CPCPLAB026

Postponed

Flow Cytometry  CPCPLAB001

Postponed

Folate Testing  CPCPLAB048

Postponed

Gamma-glutamyl Transferase  CPCPLAB056

Postponed

General Inflammation Testing  CPCPLAB049

Postponed

Genetic Testing for Adolescent Idiopathic Scoliosis

CPCPLAB060 

Postponed

Helicobacter Pylori Testing  CPCPLAB018

Postponed

Hemoglobin A1c CPCPLAB004

Postponed

Hepatitis C CPCPLAB015

Postponed

Identification of Microorganisms using Nucleic Acid Probes  CPCPLAB063

Postponed

Immune Cell Function Assay  CPCPLAB028

Postponed

Immunohistochemistry CPCPLAB069

Postponed

In Vitro Chemoresistance and Chemosensitive Assays CPCPLAB030

Postponed

Intracellular Micronutrient Analysis CPCPLAB029

Postponed

Laboratory Testing for the Diagnosis of Inflammatory Bowel Disease

CPCPLAB035

Postponed

Lyme Disease

CPCPLAB044

Postponed

Measurement of Thromboxane Metabolites for ASA Resistance

CPCPLAB031

Postponed

Molecular Testing for Chronic Heart Failure

CPCPLAB040

Postponed

Nerve Fiber Density Testing

CPCPLAB064

Postponed

Onychomycosis Testing

CPCPLAB068

Postponed

Oral Screening Lesion Identification Systems and Genetic Screening

CPCPLAB032

Postponed

Pancreatic Enzyme Testing for Acute Pancreatitis CPCPLAB047

Postponed

Parathyroid Hormone, Phosphorus, Calcium, and Magnesium Testing

CPCPLAB055

Postponed

Pathogen Panel Testing

CPCPLAB045

Postponed

Pediatric Preventive Screening 

CPCPLAB016

Postponed

Plasma HIV-1 and HIV-2 RNA Quantification for HIV Infection

CPCPLAB065

Postponed

Prenatal Screening

CPCPLAB014

Postponed

Prenatal Screening for Fetal Aneuploidy

CPCPLAB022

Postponed

Pre-Operative Testing 

CPCPLAB012

Postponed

Prescription Medication and Illicit Drug Testing in the Outpatient Setting CPCPLAB070

Postponed

Preventive Screening in Adults CPCPLAB007

Postponed

Prostate Biopsies CPCPLAB005

Postponed

Prostate Specific Antigen Testing  CPCPLAB006

Postponed

Salivary Hormone Testing CPCPLAB034

Postponed

Serum Tumor Markers for Malignancies CPCPLAB037

Postponed

Testing for Alpha-1 Antitrypsin Deficiency CPCPLAB061

Postponed

Testing for Diagnosis of Active or Latent Tuberculosis  CPCPLAB027

Postponed

Testing for Mosquito- or Tick-Related Infections CPCPLAB052

Postponed

Testing of Homocysteine Metabolism-Related Conditions CPCPLAB067

Postponed

Testosterone Testing CPCPLAB009

Postponed

Thyroid Disease Testing  CPCPLAB019

Postponed

Urinary Tumor Markers for Bladder Cancer CPCPLAB038

Postponed

Urine Culture Testing for Bacteria CPCPLAB050

Postponed

Vectra DA Blood Test for Rheumatoid Arthritis CPCPLAB039

Postponed

Venous and Arterial Thrombosis Risk Testing  CPCPLAB058

Postponed

Vitamin B12 and Methylmalonic Acid Testing CPCPLAB010

Postponed

Vitamin D CPCPLAB003

Postponed

ZIKA Virus Risk Assessment CPCPLAB042

Postponed