Professional Provider Office Manual

Reference Section - Updated 3/20/2023
Section 1: Network Overview - Updated 1/31/2023
Section 2: Network Participation - Updated 3/20/2023
Section 3: Member Engagement - Updated 1/1/2023
Section 4: Medical Management - Updated 3/20/2023
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2023
Section 5.1 General Billing
Section 5.2 Acupuncture
Section 5.3 After Hours Care
Section 5.4 Ambulance Transport Benefit - Updated 4/13/2023
Section 5.5 Anesthesia
Section 5.6 Autism - Updated 3/20/2023
Section 5.7 Behavioral Health - Updated 3/20/2023
Section 5.8 Chiropractic and Physical Medicine Services - Updated 1/1/2023
Section 5.9 Code Editing
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 7/1/2023
Section 5.15 Evaluation and Management Services
Section 5.16 Home Health Agency
Section 5.17 Incident to - Updated 1/1/2023
Section 5.18 Infusion Therapy
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services - Updated 1/1/2023
Section 5.21 Laboratory - Updated 1/31/2023
Section 5.22 Maternity Care and Delivery
Section 5.23 Medication Substitution
Section 5.24 Modifiers - Updated 1/31/2023
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 1/31/23
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study - Updated 1/1/2023
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth - Updated 1/1/2023
Section 5.38 Urgent Care Centers
Section 5.39 Colonoscopy Multiple Procedure Reduction
Section 5.40 Pharmaceutical Waste
Section 5.41 Mass immunizers - New 1/1/2023
Section 5.42 Digital Health - New 1/1/2023
Section 6: Other Coverage - Updated 1/1/2023
Section 7:Claims Submission
Section 8: Claims Resolutions
Appendix I: Online Resources
Appendix II: Forms - Updated 3/20/2023
Appendix III: Definitions - Updated 1/1/2023

Printable PDF of Entire Manual - Updated 7/1/2023