Clinical Payment and Coding Policies

Clinical payment and coding policies are based on criteria developed by specialized professional societies, national guidelines (e.g. Milliman Care Guidelines (MCG)) and the CMS Provider Reimbursement Manual. Additional sources are used and can be provided upon request. The clinical payment and coding guidelines are not intended to provide billing or coding advice but to serve as a reference for facilities and providers.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member's plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

In the event of conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents.

In the event of conflict between a Clinical Payment and Coding Policy and any provider contract pursuant to which a provider participates in and/or provides services to eligible member(s) and/or plans, the provider contract will govern.

View the current policies below:

Policy Name Policy NumberPosted
Chiropractic Services   CPCP016  08/30/2019
Pneumatic Compression Devices – Outpatient Use   CPCP022  07/12/2019
Applied Behavior Analysis   CPCP011  03/06/2019
Multiple Surgical Procedures   CPCP015  03/06/2019
Global Surgical Package   CPCP014  01/25/2019
Inpatient/Outpatient Unbundling Policy   CPCP002  01/25/2019
Co-Surgeon/Team Surgeon Modifiers    CPCP009  01/25/2019
Medical Record Documentation   OKCPCP01  09/14/2018
Preventive Services Policy   CPCP006  01/01/2019
Psychological and Neuropsychological Testing   ECPCP008  03/01/2018