Clinical Payment and Coding Policies

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

In the event of conflict between a Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides services to eligible member(s) and/or plans, the provider contract will govern.

View the current policies below:

Policy Name Policy Number & Version NumberPosted
Anesthesia Clinical Payment and Coding Information PDF Document CPCP010 06/27/2018
Applied Behavior Analysis for Autism Spectrum Disorders PDF Document CPCP011 05/28/2018
Co-Surgeon/Team Surgeon Modifiers PDF Document CPCP009 03/29/2018
Chiropractic Services PDF Document CPCP016 05/28/2018
Evaluation and Management of Emergency Department Coding CPCP003 05/28/2018
Global Surgical Package PDF Document CPCP014 03/29/2018
Hernia Repair PDF Document CPCP012 03/29/2018
Implant Payment and Coding Policy PDF Document CPCP007 06/27/2018
Increased Procedural Services (Modifier 22) PDF Document CPCP013 03/29/2018
Inpatient/Outpatient Unbundling Policy CPCP002 06/27/2018
Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy PDF Document CPCP004 05/28/2018
Observation Services Tool for Applying MCG Care Guidelines CPCP001 05/28/2018
Preventive Services Policy PDF Document CPCP006 06/04/2018
Psychological and Neuropsychological Testing PDF Document CPCP008 10/01/2017
Telemedicine and Telehealth Services TXCPCP01 04/04/2018
Wasted/Discarded Drugs and Biologicals Guideline CPCP017 07/11/2018