Policy Bulletins
The Policy Bulletins listed below represent our catalogue of medical and claim payment policies. If you are looking for a specific type of policy, choose a category from the menu on the right. You may also use the search function in the top menu to search for policies by word or phrase.
 
   


Policy #
Policy Bulletin Title

Show details for
00.01.14p
Reporting and Documentation Requirements for Anesthesia Services
00.01.18c
Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.19c
Facility Reporting of Observation Services
00.01.24f
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.01.25aq
PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services
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00.01.41b
STAT Laboratory Tests Performed in the Outpatient Hospital Setting for Health Maintenance Organization (HMO) and Point of Service (POS) Products
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00.01.44h
Never Events and Preventable Adverse Events
00.01.45
Intravenous (IV) Administration of Fluids as a Treatment of a Medical Condition or for the Preparation of Pharmaceuticals, Biologics, and other Substances
00.01.47c
Inpatient Hospital Readmission
00.01.48c
Marijuana for Medical Use
00.01.49c
Reporting Requirements for Drugs and Biologics
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00.01.52f
Always Bundled Procedure Codes
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00.01.55m
New Jersey Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Radiology Network Rules and Limited Circumstances
00.01.56a
National Correct Coding Initiative (NCCI) Code Pair Edits
00.01.59d
Care Management and Care Planning Services
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00.01.60b
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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00.01.61
Reimbursement for Components of Comprehensive Laboratory Panels
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00.01.66a
Musculoskeletal Services
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00.03.02x
Diagnostic Radiology Services Included in Capitation
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00.03.03g
Outpatient Short-Term Rehabilitation Services Included in Capitation
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00.03.06e
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
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00.03.07u
Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products
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00.03.09d
X-rays Associated with Fractures in the Office Setting
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00.03.10e
Obstetrical Ultrasounds for Members Enrolled in a Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Product
00.05.01e
Guidelines for Well Mother/Well Baby Visits Under the Mother's Option Program
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00.06.02w
Preventive Care Services (AmeriHealth)
00.09.01e
Direct Access Obstetrics/Gynecology (OB/GYN)
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00.10.01y
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.03i
Criteria for Reimbursement of Emergency Room Services
00.10.11k
Modifier 62: Two Surgeons
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
00.10.16d
Physician/Nonphysician Standby Services
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00.10.17h
Modifier 66: Surgical Team
00.10.18j
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
00.10.31c
Medical Team Conferences
00.10.32e
Prolonged Face-to-Face Physician Services
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00.10.36o
Radiologic Guidance of a Procedure
00.10.37b
Humanitarian Use Devices (HUD) and the Humanitarian Device Exemption (HDE) Process
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00.10.38
Billing Requirements for Multiple Births for Professional Providers
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00.10.39i
Billing for Professional Office-Based Services Performed in an Outpatient Office-Based Setting Located within a Facility or on a Facility Campus
00.10.40b
Reimbursement for Services Performed by Certified Registered Nurse Practitioners (CRNPs) or Physician Assistants (PAs)
00.10.41c
Telemedicine for Primary Care Services (Amerihealth Pennsylvania)
00.10.42
Telemedicine and Telehealth Services (Amerihealth New Jersey)
01.00.02b
Anesthesia Services for a Cancelled or Discontinued Procedure
01.00.08c
Preoperative Consultations Performed by Providers in Anesthesia Specialties
01.00.09c
Continuous Local Delivery of Anesthesia to Operative Sites Using an Elastomeric Infusion Pump
02.01.01d
Home Health Care Services
02.01.02c
Private Duty Nursing
02.02.01g
Hospice Care
03.00.02a
Modifier 76: Repeat Procedure by Same Physician
03.00.05i
Modifier 50: Bilateral Procedure
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03.00.06o
Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
03.00.08d
Modifiers XE, XS, XP, XU, 59
03.00.11a
Modifier 77: Repeat Procedure by Another Physician
03.00.12e
Modifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following the Initial Procedure for a Related Procedure During the Postoperative Period
03.00.15n
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period
03.00.16n
Modifier 57: Decision for Surgery
03.00.20h
Modifiers 26 (Professional Component) and TC (Technical Component)
03.00.28l
Modifier 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period
03.00.31e
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.32
Modifier 52 Reduced Services
03.00.33
Modifier 53: Discontinued Procedure
03.02.12c
Electrocardiogram (ECG/EKG) Reported with Single Photon Emission Computed Tomography (SPECT) for Myocardial Perfusion Imaging (MPI)
03.02.13e
Evaluation or Setup of a Cardiac Pacemaker Reported with an Electrocardiogram (ECG/EKG)
03.12.04c
Insertion or Application of Urinary Catheters and the Associated Supplies Provided in the Office Setting
04.00.03a
Dental Extractions Prior to Cardiac Surgery, Radiation Therapy, or Transplant Surgery
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
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05.00.01l
Pneumatic Compression Therapy Devices
05.00.04d
Food and Drug Administration (FDA) Approval of Medical Devices
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05.00.05k
Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes
05.00.08e
Continuous Passive Motion (CPM) Devices in the Home Setting
05.00.09h
Electrical Bone Growth Stimulation and Low-Intensity Ultrasound Accelerated Fracture Healing System
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05.00.11h
Therapeutic Shoes and Orthopedic Shoes
05.00.12g
Manual Wheelchairs
05.00.14i
High-Frequency Chest Wall Oscillation Devices
05.00.15p
Nebulizers and Inhalation Solutions
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05.00.21s
Durable Medical Equipment (DME) and Consumable Medical Supplies
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.25g
Cranial Remolding Orthoses (Helmets)
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05.00.26g
Home Prothrombin Time Monitoring
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.30l
Noninvasive Respiratory Assist Devices (RADs): Continuous Positive Airway Pressure (CPAP) Devices and Bi-Level Devices (AmeriHealth Adminstrators)
05.00.31e
Pulse Oximetry Devices in the Home Setting
05.00.32i
Speech and Non-Speech Generating Devices
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05.00.35e
Foot Orthotics and Other Podiatric Appliances
05.00.37f
Compression Garments
05.00.38j
Negative-Pressure Wound Therapy (NPWT) Systems
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05.00.39o
Ankle-Foot/Knee-Ankle-Foot Orthoses
05.00.42g
Patient Lifts
05.00.43f
Seat Lift Mechanisms
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05.00.44k
Repair and Replacement of Durable Medical Equipment (DME)
05.00.45k
Repair or Replacement of an External Prosthetic Device
05.00.47n
Knee Orthoses
05.00.48i
Durable Medical Equipment (DME) Not Subject to a Rental to Purchase Maximum
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05.00.50k
Ostomy Supplies
05.00.54g
Power Wheelchairs (PWCs), Power-Operated Vehicles (POVs), and Push-Rim Activated Power-Assist Devices
05.00.55i
Wheelchair Cushions and Seating
05.00.56i
Hospital Beds and Accessories
05.00.58k
Home Oxygen Therapy
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05.00.59i
Lower Limb Prostheses
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05.00.60g
Pressure-Reducing Support Surfaces
05.00.61f
Cervical Traction Devices for In-home Use
05.00.62h
Injectable Dermal Fillers
05.00.65e
Home Uterine Activity Monitoring (HUAM) Devices
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05.00.67o
Wheelchair Options and Accessories
05.00.69b
Home-Use Light Box for the Treatment of Seasonal Affective Disorder (SAD)
05.00.70b
Mechanical Stretching Devices for the Treatment of Joint Stiffness or Contractures
05.00.71c
Standing Frames
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05.00.72e
Upper Limb Prostheses
05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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05.00.74c
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
05.00.76a
Breast Pumps
05.00.77a
Subcutaneous Implantable Cardioverter Defibrillator (S-ICD) for Treating Life-threatening Ventricular Tachyarrhythmia
05.00.78
Transtympanic Micropressure Device as a Treatment of Meniere's Disease
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05.00.79a
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
06.00.01e
Computer Analysis and Generation of Automated Data in Conjunction with Diagnostic Studies
06.02.01i
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
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06.02.06o
Genetic Testing for Inherited Breast Cancer 1 (BRCA1) and Breast Cancer 2 (BRCA2) Mutations (AmeriHealth Administrators)
06.02.09g
Human Immunodeficiency Virus (HIV) Genotyping and Phenotyping (AmeriHealth Administrators)
06.02.10q
Genetic Testing for Inherited Susceptibility to Colon Cancer and Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch Syndrome) (AmeriHealth Administrators)
06.02.14h
In Vitro Chemosensitivity and Chemoresistance Assays
06.02.17e
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
06.02.18k
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (AmeriHealth Administrators)
06.02.24j
Preimplantation Genetic Testing (AmeriHealth Administrators)
06.02.26c
In Vitro Allergy Testing
06.02.27k
Assays of Genetic Expression in Tumor Tissue for Breast Cancer Prognosis (AmeriHealth Administrators)
06.02.29d
AlloMap™ Molecular Expression Testing for Heart Transplant Rejection (AmeriHealth Administrators)
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06.02.30e
Pharmacogenetic Testing to Determine Drug Sensitivity (AmeriHealth Administrators)
06.02.31f
Genetic Testing for Congenital Long QT Syndrome (AmeriHealth Administrators)
06.02.32d
Multigene Expression Assays for Predicting Recurrence in Colon Cancer (AmeriHealth Administrators)
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06.02.35s
Genetic Testing (AmeriHealth Administrators)
06.02.36b
PathFinderTG® (AmeriHealth Administrators)
06.02.37a
Immune Cell Function Assay
06.02.38c
Nerve Fiber Density Testing
06.02.39b
Measurement of Serum Antibodies to and Measurement of Serum Levels of Infliximab and Adalimumab
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
06.02.44g
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
06.02.47b
Noninvasive Prenatal Screening for Fetal Aneuploidies Using Cell-Free Fetal DNA (AmeriHealth Administrators)
06.02.49b
VeriStrat® Testing for Targeted Therapy in Non-Small Cell Lung Cancer
06.02.50
GPS Cancer™ Testing by NantHealth
06.02.51c
Testing Serum Vitamin D Levels
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06.02.52k
eviCore Lab Management Program (AmeriHealth)
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
06.02.56
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
06.03.04n
Apheresis Therapy
06.03.05e
Autologous Blood Services (Collection, Storage, Transfusion, and Perioperative Salvage)
07.00.01h
Biofeedback Therapy
07.00.02h
Intravenous Chelation Therapy
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.05f
In Vivo Allergy Sensitivity Testing
07.00.09d
Topical Oxygenation
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.00.14f
Low-level Laser Therapy (LLLT)
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
07.00.21g
Allergy Immunotherapy
07.02.05j
External Counterpulsation (ECP)
07.02.09e
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21b
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.03.03f
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
07.03.05u
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies
07.03.07q
Evaluation and Management of Autism Spectrum Disorders (ASD)
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07.03.08g
Neuropsychological Testing for Neurologically Based Conditions
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07.03.08h
Neuropsychological Testing for Neurologically Based Conditions
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07.03.09o
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.03.14n
Intraoperative Neurophysiological Monitoring (INM)
07.03.15d
Evaluation and Management (E&M) of Diabetic Peripheral Neuropathy with Loss of Protective Sensation (LOPS)
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07.03.18n
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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07.03.21j
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.22c
Transcranial Magnetic Stimulation (TMS)
07.03.23a
Autonomic Nervous System Testing
07.03.24
Laboratory-Based Vestibular Function Testing
07.03.25
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.03.26
Tumor Treating Fields
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07.05.02n
Wireless Capsule Endoscopy (WCE) as a Diagnostic Technique in Disorders of the Small Bowel, Esophagus, and Colon
07.05.06f
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.05.07c
Drug-Eluting Beads and Bland Embolization for the Treatment of Hepatic Malignancies
07.05.08a
Fecal Microbiota Transplantation (FMT)
07.06.01b
Complete Decongestive Therapy (CDT)
07.06.03b
Bioimpedance for the Detection of Lymphedema
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07.07.01n
Routine Foot Care for Certain Medical Conditions
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07.07.02j
Ultraviolet Light Therapy for the Treatment of Dermatological Conditions
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07.07.03l
Photodynamic Therapy (PDT) Using Levulan® Kerastick® (Aminolevulinic Acid HCl [ALA]) or Metvixia® (Methyl Aminolevulinate [MAL])
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
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07.07.07f
Electrical Stimulation and Electromagnetic Stimulation for the Treatment of Wounds
07.07.09f
Stem-Cell Therapy for Orthopedic Applications and Autologous Platelet-Derived Growth Factors (PDGFs)/Platelet-Rich Plasmas (PRPs) for Acute or Chronic Wound Healing and Other Miscellaneous Conditions
07.08.01f
Non-Surgical Spinal Decompression Therapy
07.08.03d
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
07.10.05k
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.10.06e
Assisted Reproductive Technology for Infertility and Oocyte Cryopreservation
07.11.01c
Smell and Taste Dysfunction Testing
07.11.02f
Measurement of Exhaled Nitric Oxide and Breath Condensate in the Diagnosis and Management of Asthma and Other Respiratory Disorders
07.12.01e
Pelvic Floor Stimulation as a Treatment of Incontinence
07.13.01g
Orthoptic/Pleoptic Training
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)