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 NumberPostedArchived Documents
Inpatient/Outpatient Unbundling Policy - Facility   CPCP002  01/14/2022 View Archive
Coordinated Home Care/Private Duty Nursing Policy   CPCP005  01/14/2022 View Archive
Preventive Services Policy V1   CPCP006  01/14/2022 View Archive
Psychological and Neuropsychological Testing   CPCP008  04/05/2021 View Archive
Co-Surgeon/Team Surgeon Modifiers   CPCP009  11/04/2021 View Archive
Anesthesia   CPCP010  10/19/2021 View Archive
Applied Behavior Analysis   CPCP011  01/14/2020 View Archive
Hernia Repair   CPCP012  06/25/2021 View Archive
Global Surgical Package - Professional Providers   CPCP014  05/11/2021 View Archive
Multiple Surgical Procedures   CPCP015  09/17/2021 View Archive
Chiropractic Care Services   CPCP016  01/14/2022 View Archive
Wasted/Discarded Drugs and Biologicals Guideline   CPCP017  01/14/2022 View Archive
Home Infusion   CPCP019  10/05/2021 View Archive
Drug Testing Clinical Payment and Coding Policy   CPCP020  01/14/2022 View Archive
Laboratory Panel Billing   CPCP021  07/06/2021 View Archive
Pneumatic Compression Devices – Outpatient Use   CPCP022  01/14/2022 View Archive
Modifier Reference Guideline   CPCP023  04/05/2021  
Evaluation and Management (E/M) Coding – Professional Provider Services   CPCP024  12/29/2020  
Corrected Claim Submissions   CPCP025  05/01/2020  
Therapeutic, Prophylactic and Diagnostic Injection and Infusion Coding V3   CPCP026  10/05/2021  
Non-Reimbursable Experimental, Investigational and/or Unproven Services (EIU) V2   CPCP028  07/06/2021 View Archive
Medical Record Documentation Guidelines   CPCP029  10/05/2021 View Archive
Trauma Activation- Facility Services   CPCP031  05/21/2021 View Archive
Intraoperative Neurophysiology Monitoring (IONM) Coding and Reimbursement Guideline   CPCP032  08/11/2021
Telemedicine and Telehealth Services   CPCP033  05/19/2021 View Archive
Unbundling Policy-Professional Providers V2   CPCP034  10/05/2021  
Paravertebral Facet Injection Procedure Coding & Billing Policy   CPCP036  01/14/2022