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 |
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.F | Cosmetic & Reconstructive Services | Documents our coverage position for cosmetic and reconstructive services | 5/1/2020 |
MN.008.C | Genetic Testing | Documents our coverage position on genetic testing | 7/1/2020 |
MN.010.C | Gender Confirmation Surgery | Documents our position on gender confirmation surgery | 9/1/2020 |
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: 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 | 6/1/2020 |
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 |
RB.015.A | Cataract Removal and Related Ophthalmologic Testing | Documents our position on cataract removal and related ophthalmologic testing | 5/1/2020 |
RB.017.B | Continuous Glucose Monitors 30-day notification |
Documents our position on continuous glucose monitors | 3/19/2021 |
RB.018.A | Medicare Readmissions | Documents our position on Medicare readmissions | 1/1/2021 |
RB.019.A | Health Care Acquired Conditions (HCAC) and Preventable Serious Adverse Events (PSAE) | Documents our position on Health Care Acquired Conditions and Preventable Serious Adverse Events | 1/1/2021 |
Claim Payment Policy Type Key: RB = Reimbursement
Drug Policy Bulletins
Our Drug policy bulletins documents our position on pharmaceutical topics and drugs.
Policy Bulletin # |
Title |
Summary |
Version Date |
DR.002.B | Intravenous Immune Globulin (IVIG) |
Documents our position regarding IVIG Therapy |
8/1/2020 |
DR.003.B | Ocrevus (Ocrelizumab) |
Documents our position on Ocrevus (Ocrelizumab).
|
5/1/2020 |
DR.004.B | Spinraza (Nusinersen) |
Documents our position on Spinraza (Nusinersen).
|
6/1/2020 |
DR.005.A | Zolgensma (onasemnogene abeparvovec-xioi) |
Documents our position on Zolgensma (onasemnogene abeparvovec-xioi).
|
3/1/2020 |
DR.006.A | Complement Inhibitors: Eculizumab (Soliris) & Ravulizumab(Ultomiris) |
Documents our position on Eculizumab (Soliris) and Ravulizumab(Ultomiris).
|
7/1/2020 |
DR.007.B | Adakveo (Crizanlizumab-tcma) |
Documents our position on Adakveo (Crizanlizumab-tcma). |
1/1/2021 |
DR.008.A | Sandostatin LAR Depot (octreotide acetate) |
Documents our position on Sandostatin LAR Depot (octreotide acetate). |
10/1/2020 |
DR.009.A | TEPEZZA® (teprotumumab-trbw) |
Documents our position on TEPEZZA® (teprotumumab-trbw). |
11/1/2020 |
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.