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	Original Implementation Date	Version Date
AD.001.C	Medicare Readmissions	Documents our position on Medicare readmissions	1/1/2014	4/1/2018
MN.005.B	E&I	Documents our coverage position for E&I Services, IDEs, and CEDs	8/1/2016	7/18/2018
MN.006.E	Cosmetic & Reconstructive Services	Documents our coverage position for cosmetic and reconstructive services	10/1/2007	11/1/2018
MN.008.B	Genetic Testing	Documents our coverage position on genetic testing	10/16/2016	5/1/2018
MN.010.B	Gender Confirmation	Documents our position on gender confirmation	11/6/2016	7/18/2018
MN.011.B	Whole Genome and Whole Exome Sequencing	Documents our position on WGS and WES	11/1/2017	12/1/2018
MN.012.B	LINX™ Reflux Management System	Documents our position on the LINX™ Reflux Management System	11/1/2017	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	1/30/2017	1/1/2019
MN.015.A	Standards of Medical Necessity	Documents our position related to medical necessity	12/1/2018	12/1/2018

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.B	Ambulance Ground Mileage Claim	Documents our reimbursement rules for ambulance ground mileage and ambulance services	10/1/2015	11/1/2018
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
RB.007.B	DME Continuous Rental	Documents our position on durable medical equipment (DME) rentals	11/1/2015	5/25/2018
RB.014.A	Observation Care   FAQ	Documents our position on Observation Care services Provides answers to common questions	3/15/2018	3/15/2018

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	Original Implementation Date	Version Date
DR.001.A	Soliris (Eculizumab)	Documents our position on Soliris (Eculizumab). Note that version "B" (below) will be in effect unitl 6/1/2019.	3/26/2018	3/26/2018
DR.001.B	Soliris (Eculizumab)	Documents our position on Soliris (Eculizumab). Note: Version B not implemented until 6/1/2019.	3/26/2018	6/1/2019
DR.002.A	Intravenous Immune Globulin (IVIG)	Documents our position regarding IVIG Therapy	9/1/2018	9/1/2018
DR.003.A	Ocrevus (Ocrelizumab)	Documents our position on Ocrevus (Ocrelizumab). Note: Not implemented until 6/1/2019.	6/1/2019	6/1/2019
DR.004.A	Spinraza (Nusinersen)	Documents our position on Spinraza (Nusinersen). Note: Not implemented until 6/1/2019.	6/1/2019	6/1/2019

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.