In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.
For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.
Policy: 00.01.25ay:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
Policy: 00.03.06f:Physical Medicine and Rehabilitation Services Eligible for Reimbursement Above Capitation to Physical and Occupational Therapy (PT/OT) Providers for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
Policy: 00.10.03j:Criteria for Reimbursement of Emergency Room Services
Policy: 00.10.39l:Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
Policy: 05.00.32j:Speech and Non-Speech Generating Devices
Policy: 07.08.03e:Medical and Surgical Treatment of Temporomandibular Joint Disorder
Policy: 10.02.02j:Chiropractic Spinal and Extraspinal Manipulation Therapy
Policy: 10.03.01l:Physical Medicine, Rehabilitation, and Habilitation Services
Policy: 11.07.01t:Hematopoietic Stem Cell Transplantation (Bone Marrow Transplant)
Policy: 12.05.01i:Outpatient Diabetes Education and Self-Management Training
Policy: 00.06.02ac:Preventive Care Services (AmeriHealth)
Policy: 11.02.27b:Percutaneous Coronary Intervention, Coronary Angiography and Arterial Ultrasound (AmeriHealth)