Provider policies

Administrative policies

Reimbursement billing policies

Policies, A	Effective date	Status
Age consistency — maternity diagnosis (PDF)	April 20, 2018	Active
Air ambulance origin and destination modifiers (PDF)	June 19, 2018	Active
Ambulance advanced life support (ALS) and basic life support (BLS) approved diagnosis (PDF)	June 19, 2018	Active
Ambulance bill type codes (PDF)	June 19, 2018	Active
Ambulance modifier QL (PDF)	June 19, 2018	Active
Ambulance policy — ambulance mileage (PDF)	June 19, 2018	Active
Ambulance policy — non-covered origins and destinations (PDF)	June 19, 2018	Active
Ambulance policy — non-covered ambulance transportation and transportation-related services (PDF)	June 19, 2018	Active
Ambulance policy — place of service (PDF)	June 19, 2018	Active
Ambulance services and required modifiers (PDF)	June 19, 2018	Active
Ambulance services (ground) (PDF)	June 19, 2018	Active
Ambulance policy — ground emergency services (PDF)	June 19, 2018	Active
Ambulance policy — supplies, services and transport (PDF)	June 19, 2018	Active
Ambulatory surgery policy (PDF)	June 19, 2018	Active
Anesthesia limit reimbursement and frequency codes (PDF)	June 25, 2018	Active
Anesthesia — maternity related (PDF)	June 24, 2018	Active

Policies, A	Age consistency — maternity diagnosis (PDF)
Effective date	April 20, 2018
Status	Active
Policies, A	Air ambulance origin and destination modifiers (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance advanced life support (ALS) and basic life support (BLS) approved diagnosis (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance bill type codes (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance modifier QL (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — ambulance mileage (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — non-covered origins and destinations (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — non-covered ambulance transportation and transportation-related services (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — place of service (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance services and required modifiers (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance services (ground) (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — ground emergency services (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulance policy — supplies, services and transport (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Ambulatory surgery policy (PDF)
Effective date	June 19, 2018
Status	Active
Policies, A	Anesthesia limit reimbursement and frequency codes (PDF)
Effective date	June 25, 2018
Status	Active
Policies, A	Anesthesia — maternity related (PDF)
Effective date	June 24, 2018
Status	Active

Policies, B–E	Effective date	Status
Bundled facility payment policy — outpatient services treated as inpatient services — revised (PDF)	July 1, 2018	Active
Bundled facility pre-admission outpatient services treated as inpatient services (24-hour window payment policy) (PDF)	July 1, 2018	Active
Cardiology — evaluation and management (E/M) services with implantable cardiac device monitoring (PDF)	July 1, 2018	Active
Cardiology — duplex scan for carotid artery stenosis (CAS) in asymptomatic adult patients (PDF)	May 2, 2018	Active
Definitive drug testing (PDF)	August 1, 2018	Active
Diagnosis code guidelines — ICD-10 laterality (PDF)	April 20, 2018	Active
Duplicate services policy — duplicate services from same NPI (PDF)	May 2, 2018	Active
Evaluation and management services (PDF)	August 1, 2018	Active
Experimental and investigational services (PDF)	June 26, 2018	Active
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (PDF)	August 1, 2021	Active

Policies, B–E	Bundled facility payment policy — outpatient services treated as inpatient services — revised (PDF)
Effective date	July 1, 2018
Status	Active
Policies, B–E	Bundled facility pre-admission outpatient services treated as inpatient services (24-hour window payment policy) (PDF)
Effective date	July 1, 2018
Status	Active
Policies, B–E	Cardiology — evaluation and management (E/M) services with implantable cardiac device monitoring (PDF)
Effective date	July 1, 2018
Status	Active
Policies, B–E	Cardiology — duplex scan for carotid artery stenosis (CAS) in asymptomatic adult patients (PDF)
Effective date	May 2, 2018
Status	Active
Policies, B–E	Definitive drug testing (PDF)
Effective date	August 1, 2018
Status	Active
Policies, B–E	Diagnosis code guidelines — ICD-10 laterality (PDF)
Effective date	April 20, 2018
Status	Active
Policies, B–E	Duplicate services policy — duplicate services from same NPI (PDF)
Effective date	May 2, 2018
Status	Active
Policies, B–E	Evaluation and management services (PDF)
Effective date	August 1, 2018
Status	Active
Policies, B–E	Experimental and investigational services (PDF)
Effective date	June 26, 2018
Status	Active
Policies, B–E	Early and Periodic Screening, Diagnosis and Treatment (EPSDT) (PDF)
Effective date	August 1, 2021
Status	Active

Policies, F–M	Effective date	Status
Hair analysis of metal testing (PDF)	July 1, 2018	Active
Incorrect bilateral increase (CC-bilateral) (PDF)	July 1, 2018	Active
Invalid bill code types (PDF)	July 23, 2018	Active
Limitations on abortions (PDF)	October 1, 2019	Active
Modifier policy — anatomical modifiers (PDF)	May 2, 2018	Active
Multiple births (PDF)	August 1, 2017	Active
Multiple surgery reduction — physician (MPR-P) (PDF)	August 14, 2018	Active

Policies, F–M	Hair analysis of metal testing (PDF)
Effective date	July 1, 2018
Status	Active
Policies, F–M	Incorrect bilateral increase (CC-bilateral) (PDF)
Effective date	July 1, 2018
Status	Active
Policies, F–M	Invalid bill code types (PDF)
Effective date	July 23, 2018
Status	Active
Policies, F–M	Limitations on abortions (PDF)
Effective date	October 1, 2019
Status	Active
Policies, F–M	Modifier policy — anatomical modifiers (PDF)
Effective date	May 2, 2018
Status	Active
Policies, F–M	Multiple births (PDF)
Effective date	August 1, 2017
Status	Active
Policies, F–M	Multiple surgery reduction — physician (MPR-P) (PDF)
Effective date	August 14, 2018
Status	Active

Policies, N–Z	Effective date	Status
Neurology policy — ambulatory or 24-hour EEG monitoring (PDF)	May 2, 2018	Active
Neurology policy — polysomnography and sleep studies (PDF)	May 2, 2018	Active
Observation services policy — direct admission without paid observation services (PDF)	July 1, 2018	Active
Observation services policy — facility observation services — frequency of observation care (PDF)	July 1, 2018	Active
Out-of-state outpatient cost-to-charge ratio (CCR) (PDF)	March 1, 2020	Active
Place of service policy — inpatient only procedures and non-inpatient surgical services (PDF)	May 2, 2018	Active
Place of service policy — inpatient only services (outpatient hospital facility) (PDF)	May 2, 2018	Active
Place of service policy — outpatient vs. inpatient (PDF)	August 1, 2018	Active
Place of service policy — special services, procedures and reports (PDF)	May 2, 2018	Active
Portable X-ray (PDF)	August 1, 2021	Active
Revenue code policy — revenue code — HCPCS code links (PDF)	May 2, 2018	Active
Unlicensed staff provider requirements (PDF)	August 4, 2018	Active
Vaccines for Children (VFC)	August 1, 2021	Active
Vitamin D testing (PDF)	December 1, 2020	Active

Policies, N–Z	Neurology policy — ambulatory or 24-hour EEG monitoring (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Neurology policy — polysomnography and sleep studies (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Observation services policy — direct admission without paid observation services (PDF)
Effective date	July 1, 2018
Status	Active
Policies, N–Z	Observation services policy — facility observation services — frequency of observation care (PDF)
Effective date	July 1, 2018
Status	Active
Policies, N–Z	Out-of-state outpatient cost-to-charge ratio (CCR) (PDF)
Effective date	March 1, 2020
Status	Active
Policies, N–Z	Place of service policy — inpatient only procedures and non-inpatient surgical services (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Place of service policy — inpatient only services (outpatient hospital facility) (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Place of service policy — outpatient vs. inpatient (PDF)
Effective date	August 1, 2018
Status	Active
Policies, N–Z	Place of service policy — special services, procedures and reports (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Portable X-ray (PDF)
Effective date	August 1, 2021
Status	Active
Policies, N–Z	Revenue code policy — revenue code — HCPCS code links (PDF)
Effective date	May 2, 2018
Status	Active
Policies, N–Z	Unlicensed staff provider requirements (PDF)
Effective date	August 4, 2018
Status	Active
Policies, N–Z	Vaccines for Children (VFC)
Effective date	August 1, 2021
Status	Active
Policies, N–Z	Vitamin D testing (PDF)
Effective date	December 1, 2020
Status	Active

Our network

Programs and services

Processes

Network providers

Tools and materials

News and updates

Policies and guidelines

Education

Doctors or hospitals

Medicines

Pharmacies

Other care providers

Provider policies

Administrative policies

Reimbursement billing policies