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Policy Bulletin Library

Our policy bulletins communicate our medical and claim payment reimbursement positions for services administered in relation to the applicable member’s benefits.

We have created two sections of the library below, one for medical policies and one for claim payment polices.

All policy documents are considered complimentary to our Provider Manual.

Medical Policy Bulletins

Our Medical Policy bulletins define medical necessity criteria and coverage positions on topics such as medical services, procedures, DME, therapies, drugs, etc.

Policy Bulletin #

Title

Summary

Original Implementation Date

Version Date

MN.002.A Hyperbaric Oxygen (HBO) Therapy Documents our coverage position on HBO therapy 4/1/2016 4/1/2016
MN.003.A ZZoma Documents our coverage position on the Zzoma positional device 6/10/2016 6/10/2016
MN.005.A E&I Documents our coverage position for E&I Services, IDEs, and CEDs 8/1/2016 8/1/2016
MN.006.C Cosmetic & Reconstructive Services Documents our coverage position for cosmetic and reconstructive services 10/1/2007 10/13/2016
MN.008.A Genetic Testing Documents our coverage position on genetic testing 10/16/2016 10/16/2016
MN.010.A Gender Confirmation Documents our position on gender confirmation 11/6/2016 11/6/2016
MN.011.A Whole Genome and Whole Exome Sequencing Documents our position on WGS and WES 11/1/2017 11/1/2017
MN.012.A LINX™ Reflux Management System Documents our position on the LINX™ Reflux Management System 11/1/2017 11/1/2017
MN.013.A Shift Nursing, Personal Care, and Medical Daycare Documents our position on Shift Nursing, Personal Care, and Medical Daycare 1/30/2017 1/30/2017

Medical Policy Type Key: AD = Administrative; MN = Medical Necessity

Claim Payment Policy Bulletins

Our Claim Payment policy bulletins provide reimbursement rules and billing guidelines necessary to ensure timely and appropriate payment.

Policy Bulletin #

Title

Summary

Original Implementation Date

Version Date

RB.001.A

Ambulance Ground Mileage Claim

Documents our reimbursement rules for ambulance ground mileage and ambulance services

10/1/2015

10/1/2015

RB.004.A

Modifier 50, Bilateral Procedure

Documents our position on modifier 50, bilateral procedure

3/31/2016

3/31/2016

RB.005.A

Modifier 25

Documents our position on Modifier 25

7/1/2016

7/1/2016

RB.006.A

STAT Labs

Provides reporting requirements and reimbursement rules for STAT laboratory tests (aka, labs)

7/1/2016

7/1/2016

Claim Payment Policy Type Key: BN = Benefit; RB = Reimbursement

Please note:

  • The effective date of select policy bulletins found in the Policy Bulletin Library above may considerably pre-date the actual date of their availability on this Policy Bulletin Library web page. This is because the Policy Bulletin Library will include PDFs of policies that have been in effect for many years, but have not been previously published on our website.
  • New and updated policy bulletins will typically be published in the Policy Bulletin Library 30 to 60 days prior to their implementation date, ensuring that your office is given appropriate notification of changes and updates that may affect your office.

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