Description
This Reimbursement Policy documents payment methodology, coding, and billing guidelines for services billed to the Health Plan. This reimbursement policy applies only to this health plan’s members, certain affiliates’ plan members, certain government or federal employee plan members, and hosted members of other Blue plans.
Use
Reimbursement Policy is used by the Health Plan to provide consistent and predictable claims payment.
Conflict with Other Documents
Reimbursement Policy facilitates the systematic application of our member contracts, provider contracts, and medical policies.
Reimbursement Policies are developed and applied in accordance with applicable state and federal law, including Center for Medicare & Medicaid Services (CMS) guidance, member benefit documents, and provider contract terms. In the event of a conflict, those governing documents control. The Health Plan may update reimbursement policies from time to time consistent with contractual and legal requirements.
Restrictions and Limitations
- We will implement quarterly updates to several of our Correct Coding Editor edits (CCE)
- Commercial Members migrated to new platform - CMS sourced edits and Lyric sourced edits within 30 days of their effective date. Updates will be applied in a manner consistent with applicable state or federal law. Claims received before our systems are updated will not be adjusted. (For National Coverage Determination (NCD)/Local Coverage Determination (LCD) updates please see Coding Toolkit).
- Commercial and Medicaid Expansion Members not migrated to new platform - CMS sourced edits within 30 days of their effective date, typically retro-active to the 1st day of the quarter. Claims received before our systems are updated will only occur if updates take more than 30 days to implement from the effective date of the edit.
- Reimbursement Policy shall be interpreted and applied in accordance with applicable law, provider contracts, and member benefit documents.
- Reimbursement Policy does not determine the schedule of benefits. Rather, Reimbursement Policy supports the schedule of benefits by establishing payment rules, coding hierarchy and related processing systems' edits.
- Health care facilities, physicians and other health care providers are expected to exercise their medical judgment in providing the most appropriate care. Reimbursement policy is not intended to dictate medical practice and does not constitute medical advice. However, the information which is provided to the plan must be accurate, complete, and truthful.
- Reimbursement Policy is the property of the Health Plan and you are strictly prohibited from using it for any commercial use whatsoever. Commercial use does not include use of the Reimbursement Policy related to benefit payment for health care services received by one of our members.
- Current Procedural Terminology CPT® codes and descriptions are the property of the American Medical Association with all rights reserved. You are strictly prohibited from using CPT® codes for any unauthorized use whatsoever.
- The coding software guidelines are incorporated into the Reimbursement Policy by reference. Thus, to the extent there are situations not documented in the Reimbursement Policy, coding software guidelines control.
- Reimbursement Policy may be revised from time to time. The Health Plan will provide advanced notice based on provider contract language.
- Migrated Members –
- ClaimsXten clinical edit content that is proprietary to Lyric will be installed on an ongoing basis, without prior written notice, to support existing reimbursement policies.
- Claritev payment integrity service content is proprietary and used as a secondary editor supporting our existing policies and edits.
