Skip navigation

Sub-navProviders

Tools and Resources
print

Policy Bulletin Library

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

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

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, etc.

Policy Bulletin #

Title

Summary

Version Date

AD.001.C Medicare Readmissions Documents our position on Medicare readmissions 4/1/2018
MN.005.B Experimental and Investigational Services, Investigational Device Exemption (IDE), and Coverage with Evidence Development (CED) Documents our coverage position for E&I Services, IDEs, and CEDs 7/18/2018
MN.006.E Cosmetic & Reconstructive Services Documents our coverage position for cosmetic and reconstructive services 11/1/2018
MN.008.B Genetic Testing Documents our coverage position on genetic testing 5/1/2018
MN.010.B Gender Confirmation Surgery Documents our position on gender confirmation surgery 7/18/2018
MN.011.C Whole Genome Sequencing/Whole Exome Sequencing Updates our coverage position on WGS and WES 12/1/2019
MN.012.B LINX™ Reflux Management System Documents our position on the LINX™ Reflux Management System 12/1/2018
MN.013.B Shift Nursing, Personal Care, and Medical Daycare Documents our position on the shift care, personcal care, and medical daycare 1/1/2019
MN.015.A Standards of Medical Necessity Documents our position related to medical necessity 12/1/2018
MN.016.A Injectable/Specialty Drugs Prior Authorization Requirements Documents our prior authorization requirements for injectable/specialty drugs 12/1/2019
MN.020.A Peroral Endoscopic Myotomy (POEM) Documents our position related to Peroral Endoscopic Myotomy (POEM) 11/1/2019

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

Version Date

RB.001.B Ambulance Ground Mileage Claim Documents our reimbursement rules for ambulance ground mileage and ambulance services 11/1/2018
RB.004.A Modifier 50, Bilateral Procedure Documents our position on modifier 50, bilateral procedure 3/31/2016
RB.005.A Modifier 25 Documents our position on Modifier 25 7/1/2016
RB.006.A STAT Labs Provides reporting requirements and reimbursement rules for STAT laboratory tests (aka, labs) 7/1/2016
RB.007.B DME Continuous Rental Documents our position on durable medical equipment (DME) rentals 5/25/2018
RB.009.A Sepsis and Severe Sepsis DRG Clinical Validation Review 30 day notification of our position on Sepsis and Severe Sepsis DRG Clinical Validation review 3/1/2020
RB.012.A Professional Telehealth Services Documents our coverage position on professional telehealth services 12/1/2019
RB.014.B Observation Care

 

FAQ
Documents our position on Observation Care services

Provides answers to common questions

12/4/2019

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

Drug Policy Bulletins

Our Drug policy bulletins documents our position on pharmaceutical topics and drugs.

Policy Bulletin #

Title

Summary

Version Date

DR.001.B

Soliris (Eculizumab)

 

Documents our position on Soliris (Eculizumab).

 

6/1/2019

DR.002.A Intravenous Immune Globulin (IVIG)

Documents our position regarding IVIG Therapy

9/1/2018

DR.003.A Ocrevus (Ocrelizumab)

Documents our position on Ocrevus (Ocrelizumab).

 

6/1/2019
DR.004.A Spinraza (Nusinersen)

Documents our position on Spinraza (Nusinersen).

 

6/1/2019
DR.005.A Zolgensma (onasemnogene abeparvovec-xioi)

Documents our position on Zolgensma (onasemnogene abeparvovec-xioi).

 

2/1/2020

Drug Policy Type Key: DR = Drug

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.