Reimbursement Methodology for Non-Participating Providers

Policy ID: Adm 135

Effective Date: January 01, 2027

Last Reviewed: June 12, 2026

Applies To: Migrated Commercial

This policy applies to Non-Participating (NonPar) facilities, physicians and other qualified health care professionals, including but not limited to, outpatient hospitals, ambulatory surgical centers (ASCs), birth centers, outpatient behavioral health treatment facilities, and independent laboratories.

Definitions

Code/Term

Code Description/Term Definition

Non-Participating (NonPar) Provider

Are physicians, facilities, and other qualified health care professionals who have not entered into a contractual agreement with our health plan. Also referred to as Out-of-Network Provider.

Policy Statement

Claims submitted by NonPar providers will be processed according to the NonPar payment methodology in place, at the time of service. Claims may be subject to, but are not limited to, the following:

Bundled services may include the application of, but are not limited to, the following:
- National Correct Coding Initiative (NCCI)
- Correct Code Editor (CCE) Code Pairs (Not applicable to Medicare Advantage)
- ClaimsXten™ Unbundled Code Pairs (Not applicable to Medicare Advantage)
- Incidental Unlisted Codes
Clinical Edits may include, but are not limited to, the following:
- Non-Reimbursable Services
- Unlisted Code Review
- Investigational Denials (Not applicable to Medicare Advantage)
- Not Medically Necessary Denials
- Cosmetic Denials (Not applicable to Medicare Advantage)
- Benefit Denials
National Physician Fee Schedule Relative Value File (NPFSRVF) pricing rules including, but are not limited to, the following:
- Procedure Code Status Indicators
- Global Periods
- Modifier Pricing, including:
  - Professional/Technical Component
  - Multiple Service Reduction (MSR)
  - Multiple Procedure Pricing Reduction (MPPR) (Applicable to Medicare Advantage)
  - Bilateral Pricing
  - Assistant Surgeon Pricing
  - Co-Surgeon, Team Surgeon Pricing
- ClaimsXten™ Rules
- Claritev Secondary Editor Edits
- Medically Unlikely Edits (MUEs)
- Integrated Outpatient Code Editor (I/OCE) clinical edits
- Inclusive Facility Fee Services (i.e., ASCs)
- Correct Coding Validation Audits
- Medical Policies, Reimbursement Policies and Administrative Manual
- Reimbursement at the lesser of billed charges or the NonPar reimbursement methodology allowed amount.
- Freestanding ASC payment methodology is based on Centers for Medicare & Medicaid Services (CMS) ASC payment system, as well as CMS Outpatient Prospective Payment System (OPPS) with our health plans modifications.
- Outpatient Hospital payment methodology is based on CMS Outpatient Prospective Payment System (OPPS).
- The Federal No Surprises Act (NSA). Reimbursement will be paid at the Qualified Payment Amount (QPA). (Not applicable to Medicare Advantage)

References

Cross References

Adm 101 - Global Days
Adm 105 - Bundling Edits
Adm 107 - Non-Reimbursable Services
Adm 108 - Incidental Procedures
Adm 114 - Medicare-Based Fee Effective Dates
Adm 120 - Maximum Daily Units
Adm 121 - Ambulance Guidelines
Adm 125 - Implants, Implant Components, Medical and Surgical Supplies for All Procedures
Adm 129 - Correct Coding Guidelines
Mod 101 - Modifier 51 and Multiple Procedure Logic
Mod 103 - Modifier 25; Significant Separately Identifiable E&M Service
Mod 105 - Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service
Mod 106 - Modifier 26; Professional Component, Modifier TC; Technical Component
Mod 108 - Modifier 50; Bilateral Procedure
Mod 109 - Modifiers 80, 81, 82, AS; Assistant at Surgery
Mod 113 - Modifier 62; Two Surgeons/Co-Surgeons
Mod 114 - Modifier 66; Surgical Team

Disclaimer

Your use of this Reimbursement Policy constitutes your agreement to be bound by and comply with the terms and conditions of the Reimbursement Policy Disclaimer.

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