Reimbursement Policy

The purpose of our Reimbursement Policy Manual is to document the sources and principles used in writing our Reimbursement Policies. This information is to be used as a general reference resource regarding our Reimbursement Policies and not intended to address every aspect of a reimbursement situation. Reasonable discretion may be used in applying our Reimbursement Policies to individual situations.

The following nationally recognized sources are consulted in the development of our health plan Reimbursement Policies.

• Centers for Medicare & Medicaid Services (CMS) written policy
• CMS Local Carrier and National Carrier Determinations (LCD NCD)
• CMS Manuals and Publications
• CPT Assistant
• CPT Manual, including code definitions and associated text
• Federal Register
• HCPCS Manual, including code definitions and associated text
• Integrated Outpatient Code Editor (I/OCE)
• International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) official guidelines for coding and reporting
• International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) official guidelines for coding and reporting
• Medically Unlikely Edits
• National Correct Coding Policy Manual for Part B Medicare Carriers (NCCI)
• National Physician Fee Schedule Relative Value File