Table of Contents
PAYMENT POLICY HISTORY ........................................................................................................................... 1
APPLICABLE PRODUCTS ................................................................................................................................ 1
TABLE OF CONTENTS ..................................................................................................................................... 2
PAYMENT POLICY OVERVIEW ....................................................................................................................... 5
POLICY DEFINITIONS ..................................................................................................................................... 5
ENROLLEE ELIGIBILITY CRITERIA.................................................................................................................... 6
ELIGIBLE PROVIDERS OR FACILITIES .............................................................................................................. 7
Provider ................................................................................................................................................. 7
Facility ................................................................................................................................................... 7
Other and/or Additional Information ................................................................................................... 7
EXLUDED PROVIDER TYPES ........................................................................................................................... 7
MODIFIERS, CPT, HCPCS, AND REVENUE CODES .......................................................................................... 8
General Information ............................................................................................................................. 8
Modifiers ............................................................................................................................................... 8
CPT and/or HCPCS Code(s) .................................................................................................................... 8
Revenue Codes ...................................................................................................................................... 9
PAYMENT INFORMATION ............................................................................................................................. 9
Payment Guidelines .............................................................................................................................. 9
Time Based Services ............................................................................................................................ 13
BILLING REQUIREMENTS AND DIRECTIONS ................................................................................................ 13
General Information ........................................................................................................................... 13
Billing Guidelines ................................................................................................................................. 16
PRIOR AUTHORIZATI0N, NOTIFICATION AND THRESHOLD INFORMATION ............................................... 17
Prior Authorization, Notification, and Threshold Requirements ........................................................ 17