We periodically update our payment policies to give you the most up-to-date information and correct codes.
- Acute Inpatient Hospital Admissions Payment Policy (PDF)
- Ambulance Transport Services Payment Policy (PDF)
- Anesthesia Services Payment Policy (PDF) — Revised April 13, 2012
- Assistant Surgeon (Modifiers 80, 81, 82, AS) Payment Policy (PDF)
- Bilateral Procedures (Modifier 50) Payment Policy (PDF)
- Child Adolescent Needs and Strengths (CANS) Payment Policy (PDF)
- Chiropractic Services Payment Policy (PDF)
- Coordination of Benefits (COB)/Third-party Liability (TPL) Policy (PDF)
- Discontinued Procedure (Modifier 53) Payment Policy (PDF)
- Distinct Procedural Services (Modifier 59) Payment Policy (PDF) — Revised September 27, 2011
- Drug Screening Payment Policy (PDF)
- Durable Medical Equipment and Medical Supplies Payment Policy (PDF)
- E/M Services (Modifier 25) Payment Policy (PDF) — Revised January 3, 2012
- Early Intervention (EI) Services Payment Policy (PDF)
- Emergency Room Services Payment Policy (PDF)
- EPSDT and PPHSD Screening Services Payment Policy (PDF)
- Facility Maternity Services Payment Policy (PDF)
- Fluoride Varnish Payment Policy (PDF)
- Genetic Testing Payment Policy (PDF)
- HCPCS Code T1015 (All-inclusive Clinic Visit) Payment Policy (PDF)
- Home Health Care Services Payment Policy (PDF)
- Hospital Hierarchy Payment Policy (PDF)
- Hospital Newborn Services Payment Policy (PDF)
- Individual Consideration Services Payment Policy (PDF)
- Member Enrollment Retroactivity Payment Policy (PDF) — New policy posted March 2, 2012
- Modifier 51 (Multiple Procedures) Payment Policy (PDF)
- Modifier 62 (Two Surgeons) Payment Policy (PDF)
- Nurse Practitioner as Primary Care Provider Payment Policy (PDF) — Revised January 3, 2012
- Observation Services Payment Policy (PDF)
- Obstetric Anesthesia Services Payment Policy (PDF)
- Opioid Replacement Therapy Payment Policy (PDF) — New policy posted May 11, 2012
- Orthotic Services Payment Policy (PDF)
- Out-of-state Facility and Professional Services Payment Policy (PDF)
- Out-of-state Payment Policy: Full-time, Dependent Students Ages 18-26 (Network Health Extend) (PDF)
- Outpatient Therapy Services Payment Policy (PDF) — Revised March 27, 2012
- Payment Adjustments Payment Policy (PDF)
- Podiatry Services Payment Policy (PDF)
- Primary Care Services Payment Policy (PDF)
- Prosthetic Services Payment Policy (PDF)
- Radiology Imaging Services Payment Policy (PDF)
- Reduced Service (Modifier 52) Payment Policy (PDF)
- Serious Reportable Events Payment Policy (PDF)
- Specialty Services Referral Requirement Payment Policy (PDF)
- Therapeutic Radiology Services Payment Policy (PDF)
- Timely Filing of Claim Submissions and Adjustment Requests Policy (PDF)
- Unusual Procedural Services (Modifier 22) Payment Policy (PDF)
- Vaccine and Immunization Services Payment Policy (PDF) — Revised September 2, 2011
- Vision Services Payment Policy (PDF)
Adherence to our payment policies does not guarantee payment if the service is not part of a member’s benefit plan. Please call us at 888-257-1985 to verify that a service is covered, to verify member eligibility, and for additional information on our payment policies.