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. 

For other policies, select the policy name below for more information.

Policy Name Policy Number Effective Date Archive
Anesthesia Clinical Payment and Coding Information CPCP010 6/1/2024 View
Anesthesia Clinical Payment and Coding Information CPCP010 3/14/2023 View
Applied Behavior Analysis CPCP011 5/23/2023 View
Chiropractic Services CPCP016 1/12/2024 View
Corrected Claim Submissions CPCP025 5/1/2020 N/A
Co-Surgeon/Team Surgeon Modifiers CPCP009 1/12/2024 View
Drug Testing Clinical Payment and Coding Policy CPCP020 12/1/2023 View
Emergency Department Evaluation and Management (EM) Services Coding - Facility Services CPCP003 7/20/2023 View
Emergency Department Evaluation and Management (EM) Services Coding - Professional Services CPCP042 11/1/2023 N/A
Evaluation and Management (E/M) Coding – Professional Provider Services CPCP024 12/1/2023 View
Global Surgical Package CPCP014 1/12/2024 View
Hernia Repair CPCP012 5/3/2023 View
Home Health Care/Private Duty Nursing CPCP005 10/30/2023 View
Home Infusion CPCP019 10/23/2023 View
Implant Payment and Coding Policy CPCP007 2/2/2023 View
Increased Procedural Services (Modifier 22) CPCP013 1/12/2024 View
Inpatient Readmissions CPCP027 10/11/2023 View
Inpatient Readmissions CPCP027 12/1/2021 View
Inpatient/Outpatient Unbundling Policy CPCP002 12/21/2023 View
Intraoperative Neurophysiology Monitoring Coding and Reimbursement Guideline CPCP032 9/5/2023 View
Laboratory Panel Billing Guideline CPCP021 6/21/2023 View
Medical Record Documentation Guidelines CPCP029 10/30/2023 View
Modifier Reference Guideline CPCP023 1/12/2024 View
Multiple Surgical Procedures CPCP015 1/12/2024 View
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy CPCP004 11/17/2023 View
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) CPCP028 5/15/2024 View
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) CPCP028 12/1/2023 View
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) CPCP028 1/15/2024 View
Observation Services Policy CPCP001 7/6/2023 View
Outpatient Facility and Hospital Claims: Revenue Codes Requiring CPT or HCPCS Codes CPCP018 10/30/2023 View
Outpatient Facility Service(s) Overlapping During an Inpatient Stay CPCP039 9/1/2023 N/A
Outpatient Services Prior to an Inpatient Admission CPCP038 2/9/2024 View
Paravertebral Facet Injection Procedure Coding & Billing Policy CPCP036 10/30/2023 View
Physical Medicine and Rehabilitation Services CPCP040 1/12/2024 View
Pneumatic Compression Devices CPCP022 2/9/2024 View
Point-of-Care Ultrasound Examination Guideline CPCP030 9/5/2023 View
Preventive Services Policy CPCP006 1/1/2024 View
Psychological and Neuropsychological Testing CPCP008 11/13/2023 View
Sepsis Policy CPCP041 5/22/2023 N/A
Telemedicine and Telehealth Services CPCP033 12/1/2023 View
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding CPCP026 5/4/2023 View
Transfer Diagnosis Related Group (tDRG) CPCPILtDRG 1/1/2024 N/A
Trauma Activation - Facility Services CPCP031 7/11/2023 View
Unbundling Professional CPCP034 5/4/2023 View
Unlisted/Not Otherwise Classified (NOC) Coding CPCP035 9/2/2022 View
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 2/19/2024 View