Clinical and payment policies

We use health care claims payment policies to help administer payment rules based on generally accepted principles of correct coding. These policies help determine whether health care services are correctly coded for reimbursement. 

Generally accepted coding principles inform each payment rule. These principles include, but aren’t limited to:

• Claims processing guidelines referenced by the Centers for Medicare & Medicaid Services (CMS) 

• Medicare Claims Processing Manual (Publication 100-04) for physicians/nonphysician practitioners

• The CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits) 

• Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services

• Health plan clinical policies based on the appropriateness of health care and medical necessity 

• State-specific claims reimbursement guidance

We may use a vendor that applies payment policies to specific services. In these situations, we may also use the vendor’s guidelines to determine whether a service has been correctly coded.