Professional Provider Office Manual

Reference Section - Updated 1/1/2021
Section 1: Network Overview - Updated 1/1/2021
Section 2: Network Participation - Updated 1/1/2021
Section 3: Member Engagement - Updated 1/1/2021
Section 4: Medical Management - Updated 1/1/2021
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2021
Section 5.1 General Billing
Section 5.2 Acupuncture
Section 5.3 After Hours Care - Updated 1/1/2021
Section 5.4 Ambulance Transport Benefit - Updated 1/1/2021
Section 5.5 Anesthesia
Section 5.6 Autism
Section 5.7 Behavioral Health - Updated 5/27/20
Section 5.8 Chiropractic and Physical Medicine Services - Updated 1/1/2021
Section 5.9 Code Editing - Updated 1/1/2021
Section 5.10 Concierge Medicine
Section 5.11 Dialysis
Section 5.12 Dietitian
Section 5.13 Drug Screening Assays
Section 5.14 Durable Medical Equipment/Home Medical Equipment - Updated 8/1/2021
Section 5.15 Evaluation and Management Services - Updated 1/20/2021
Section 5.16 Home Health Agency - Updated 1/1/2021
Section 5.17 Incident to
Section 5.18 Infusion Therapy - Updated 5/1/2021
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services - Updated 7/31/20
Section 5.21 Laboratory - Updated 1/1/2021
Section 5.22 Maternity Care and Delivery -Updated 1/1/2021
Section 5.23 Medication Substitution
Section 5.24 Modifiers
Section 5.25 Multiple Procedures
Section 5.26 Multiple Service Reduction for Diagnostic Imaging Services
Section 5.27 Nasal Endoscopy Procedures
Section 5.28 Nucleic Acid Probe Services
Section 5.29 Nurse Practitioner and Physician Assistant Services
Section 5.30 Ordering/Referring Provider Requirements
Section 5.31 Pass-through Billing and Billing for Services Not Rendered
Section 5.32 Place of Service - Updated 4/13/20
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth - Updated 7/1/2021
Section 5.38 Urgent Care Centers - Updated 1/1/2021
Section 5.39 Colonoscopy Multiple Procedure Reduction - Updated 9/1/20
Section 5.40 Pharmaceutical Waste - New 1/1/2021
Section 6: Other Coverage
Section 7:Claims Submission - Updated 1/1/2021
Section 8: Claims Resolutions
Appendix I: Online Resources - Updated 1/1/2021
Appendix II: Forms - Updated 1/1/2021
Appendix III: Definitions

Printable PDF of Entire Manual - Updated 8/1/2021