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

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00.01.14r
Reporting and Documentation Requirements for Anesthesia Services
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00.01.18d
Reimbursement for Associated Services Performed in Conjunction with Dental Care
00.01.19d
Facility Reporting of Observation Services
00.01.24h
Obsolete or Unreliable Diagnostic Tests and Medical Services
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00.01.25ax
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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00.01.52i
Always Bundled Procedure Codes
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00.01.55o
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
00.01.59f
Care Management and Care Planning Services
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00.01.60d
Multiple Procedure Payment Reduction (MPPR) on Certain Diagnostic Services
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00.01.61a
Reimbursement for Components of Comprehensive Laboratory Panels
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00.01.66b
Musculoskeletal Services (AmeriHealth)
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00.01.68
Multiple Procedure Payment Reduction Guidelines for Physical, Occupational, and Speech Therapy Services
00.01.69
Consultation Services
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00.03.02aa
Diagnostic Radiology Services Included in Capitation
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00.03.03h
Outpatient Short-Term Rehabilitation Services Included in Capitation
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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
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00.03.07y
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
00.05.01f
Guidelines for Home Care Visits Following Inpatient Maternity Stay
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00.06.02ac
Preventive Care Services (AmeriHealth)
00.09.01f
Direct Access to Obstetrics/Gynecology (OB/GYN) Services
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00.10.01ab
Services Paid Above Capitation for Health Maintenance Organization (HMO) and Health Maintenance Organization Point-of-Service (HMO-POS) Primary Care Providers
00.10.03j
Criteria for Reimbursement of Emergency Room Services
00.10.11l
Modifier 62: Two Surgeons
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00.10.15c
Cast and Splint Applications and Associated Supplies Provided in the Office Setting
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00.10.17i
Modifier 66: Surgical Team
00.10.18k
Modifiers for Assistant-at-Surgery Services: 80, 81, 82, and AS
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00.10.36q
Radiologic Guidance of a Procedure
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00.10.38a
Billing Requirements for Multiple Births for Professional Providers
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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
00.10.40d
Incident To and Non-Incident To Services Performed by Certified Registered Nurse Practitioners (CRNPs) and Physician Assistants (PAs)
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
03.00.02b
Modifier 76: Repeat Procedure or Service by Same Physician or Qualified Health Professional
03.00.05k
Modifier 50: Bilateral Procedure
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03.00.06r
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
03.00.08e
Modifiers XE, XS, XP, XU, and 59
03.00.11b
Modifier 77: Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional
03.00.12f
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
03.00.15o
Modifier 24: Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
03.00.16o
Modifier 57 Decision for Surgery
03.00.20j
Modifiers 26 (Professional Component) and TC (Technical Component)
03.00.28m
Modifier 79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
03.00.31f
Modifiers for Split or Shared Surgical Services (Modifiers 54, 55, and 56)
03.00.32a
Modifier 52 Reduced Services
03.00.33a
Modifier 53 Discontinued Procedure
04.00.05d
Extraction of Bony Impacted Teeth and Exposure of Impacted Teeth
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05.00.01l
Pneumatic Compression Therapy Devices
05.00.04e
Coverage of Medical Devices
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05.00.05l
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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05.00.11i
Therapeutic Shoes and Orthopedic Shoes
05.00.12g
Manual Wheelchairs
05.00.14j
High-Frequency Chest Wall Oscillation Devices
05.00.15q
Nebulizers and Inhalation Solutions
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05.00.21u
Durable Medical Equipment (DME) and Consumable Medical Supplies
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05.00.24q
Short-term Interstitial Continuous Glucose Monitoring Systems (CGMSs)
05.00.25i
Cranial Remolding Orthoses (Helmets)
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05.00.26i
Home Prothrombin Time Monitoring
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05.00.29k
Automatic External Cardioverter Defibrillators (Wearable and Nonwearable)
05.00.30m
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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05.00.35f
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
05.00.39o
Attachment A (HCPCS Codes) to 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
05.00.48j
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
05.00.58l
Home Oxygen Therapy
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05.00.59j
Lower Limb Prostheses
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05.00.60h
Pressure-Reducing Support Surfaces
05.00.61f
Cervical Traction Devices for In-home Use
05.00.62h
Injectable Dermal Fillers
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05.00.67p
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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05.00.72f
Upper Limb Prostheses
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05.00.73c
Neuromuscular Electrical Stimulators (NMES) and Functional Electrical Stimulators (FES)
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05.00.74d
Transcutaneous Electrical Nerve Stimulators (TENS) and Associated Supplies
05.00.75
Percutaneous Electrical Nerve Stimulation (PENS) and Percutaneous Neuromodulation Therapy (PNT)
05.00.76c
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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05.00.79b
Insulin Pumps and Long term Interstitial Continuous Glucose Monitoring Systems
05.00.80a
Cranial Electrotherapy Stimulation
06.02.01j
Lyme Disease: Diagnosis and Intravenous (IV) Antibiotic Therapy
06.02.04d
Fetal Fibronectin Enzyme (fFN) Immunoassay
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06.02.06p
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)
06.02.14i
In Vitro Chemosensitivity and Chemoresistance Assays
06.02.17h
Serodiagnosis of Inflammatory Bowel Disease (IBD) and the Prometheus® IBD sgi Diagnostic™ Test
06.02.18l
Pharmacogenetics and Metabolite Monitoring for Using Azathioprine (AZA)/6-Mercaptopurine (6-MP) Therapy (AmeriHealth Administrators)
06.02.24j
Preimplantation Genetic Testing (AmeriHealth Administrators)
06.02.26d
In Vitro Allergy Testing
06.02.27l
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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06.02.35x
Genetic Testing (AmeriHealth Administrators)
06.02.36c
Molecular Testing for the Management of Pancreatic Cysts or Barrett's Esophagus (AmeriHealth Administrators)
06.02.37a
Immune Cell Function Assay
06.02.38d
Nerve Fiber Density Testing
06.02.39d
Measurement of Serum Antibodies to and Measurement of Serum Levels of Biologics
06.02.43b
Proteomic (Protein)-Based Testing for the Evaluation of Ovarian (Adnexal) Masses Using OVA1® Test and Risk of Ovarian Malignancy Algorithm (ROMA™)
06.02.44m
Presumptive and Definitive Drug Testing in Substance Abuse and Pain Management Treatments
06.02.45
Vectra® DA Blood Test for Rheumatoid Arthritis
06.02.47d
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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06.02.52q
eviCore Lab Management Program (AmeriHealth)
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06.02.54
Cobalamin (Vitamin B12), Folic Acid, and Homocysteine Testing
06.02.55
Therapeutic Drug Monitoring for Antidepressants, Antipsychotics, or Antiepileptics
06.02.56b
Noninvasive Techniques for the Evaluation and Monitoring of Individuals with Chronic Liver Disease
06.03.04n
Apheresis Therapy
07.00.01i
Biofeedback Therapy
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07.00.02i
Intravenous Chelation Therapy
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07.00.03n
Full-Body Monoplace or Multiplace Chamber Hyperbaric Oxygen Therapy
07.00.05g
In Vivo Allergy Sensitivity Testing
07.00.09d
Topical Oxygenation
07.00.10i
Photodynamic Therapy (PDT) Using Porfimer Sodium (Photofrin®)
07.00.14g
Low-level Laser Therapy (LLLT)
07.00.15l
Reimbursement for the Administration of Immunizations
07.00.20f
Routine Costs Associated with Qualifying Clinical Trials
07.00.21i
Allergy Immunotherapy
07.02.05j
External Counterpulsation (ECP)
07.02.09g
Ambulatory Blood Pressure Monitoring (ABPM) and Home Blood Pressure Monitoring (HBPM) Devices
07.02.21e
Ambulatory Electrocardiography (AECG) Monitoring and Mobile Cardiac Outpatient Telemetry (MCOT) Monitoring
07.02.22a
Esophagogastroduodenoscopy (EGD) and Endoscopic Retrograde Cholangiopancreatography (ERCP)
07.03.03g
Medical Evaluation and Management for Attention-Deficit Hyperactivity Disorder (ADHD)
07.03.05w
Sleep Disorder Testing and Positive Airway Pressure Therapy Services and Supplies (AmeriHealth)
07.03.07t
Evaluation and Management of Autism Spectrum Disorder (ASD)
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07.03.08i
Neuropsychological Testing for Neurologically Based Conditions
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07.03.09p
Electromyography (EMG) Studies: Needle EMG, Surface EMG (SEMG)
07.03.10e
Magnetoencephalography (MEG) with Magnetic Source Imaging (MSI)
07.03.14o
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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07.03.18o
Nerve Conduction Studies (NCS) and Related Electrodiagnostic Studies
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07.03.21k
Electromyography (EMG) (Needle and Non-Needle) of the Anal or Urethral Sphincter
07.03.22d
Transcranial Magnetic Stimulation (TMS)
07.03.23c
Autonomic Nervous System Testing
07.03.24a
Laboratory-Based Vestibular Function Testing
07.03.25a
Nonemergent Inpatient Video Electroencephalogram (EEG) Monitoring and Ambulatory EEG Monitoring in the Home
07.03.26a
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
07.05.06g
Transcatheter Arterial Chemoembolization (TACE) of Hepatic Malignancies
07.05.07d
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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07.07.01o
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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07.07.03m
Photodynamic Therapy (PDT) Using Levulan® Kerastick® or Ameluz® (Aminolevulinic Acid HCl [ALA])
07.07.05b
Photography, Including Documentation and Record-Keeping Photography, Whole Body Integumentary Photography, Dermoscopy, and Dermatoscopy
07.07.09g
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
07.08.03e
Medical and Surgical Treatment of Temporomandibular Joint Disorder
07.10.04c
Parenterally Administered Terbutaline Sulfate for the Prevention or Treatment of Pre-Term Labor
07.10.05m
Noncontraceptive Use of the Levonorgestrel-Releasing Intrauterine System
07.10.06h
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
07.13.01h
Orthoptic/Pleoptic Training
07.13.05k
Photodynamic Therapy (PDT) Using Verteporfin (Visudyne®)
07.13.06k
Scanning Computerized Ophthalmic Diagnostic Imaging (SCODI)
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07.13.07j
Corneal Pachymetry Using Ultrasound
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07.13.08e
Partial Coherence Interferometry
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07.13.11i
Contact Lenses for the Treatment of Persistent (Corneal) Epithelial Defects
07.13.12d
Instrument-Based Vision Screening
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07.13.13c
Prescription Lenses and Visual Devices
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08.00.08j
Radioimmunotherapy with Ibritumomab Tiuxetan (Zevalin®) (AmeriHealth Administrators)
08.00.10a
Luspatercept–aamt (Reblozyl®)
08.00.12
Fam-trastuzumab deruxtecan-nxki (Enhertu®)
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08.00.13v
Immune Globulin Intravenous (IVIG), Subcutaneous (SCIG)
08.00.15f
Off-label Coverage for Prescription Drugs and/or Biologics