Professional Provider Office Manual 2024

Reference Section - Updated 1/31/2024
Section 1: Network Overview - Updated 1/1/2024
Section 2: Network Participation - Updated 1/31/2024
Section 3: Member Engagement - Updated 1/1/2024
Section 4: Medical Management - Updated 6/17/2024
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2024
Section 5.1 General Billing - Updated 1/1/2024
Section 5.2 Acupuncture
Section 5.3 After Hours Care
Section 5.4 Ambulance Transport Benefit - Updated 1/1/2024
Section 5.5 Anesthesia - Updated 1/1/2024
Section 5.6 Autism
Section 5.7 Behavioral Health - Updated 1/31/2024
Section 5.8 Chiropractic and Physical Medicine Services - Updated 1/1/2024
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 and Supplies - Updated 7/1/2024
Section 5.15 Evaluation and Management Services - Updated 1/31/2024
Section 5.16 Home Health Agency
Section 5.17 Incident to
Section 5.18 Infusion Therapy - Updated 1/31/2024
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services
Section 5.21 Laboratory
Section 5.22 Maternity Care and Delivery - Updated 1/1/2024
Section 5.23 Medication Substitution
Section 5.24 Modifiers - Updated 1/1/2024
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 - Updated 1/1/2024
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 1/1/2024
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study - Updated 1/1/2024
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth - Updated 1/31/2024
Section 5.38 Urgent Care Centers
Section 5.39 Colonoscopy Multiple Procedure Reduction
Section 5.40 Pharmaceutical Waste
Section 5.41 Mass Immunizers
Section 5.42 Digital Health
Section 5.43 Fertility Preservation Services - New 1/1/2024
Section 5.44 Medical Record Documentation - New 1/1/2024
Section 5.45 Dental Billing - New 3/18/2024
Section 6: Other Coverage - Updated 1/1/2024
Section 7: Claims Submission
Section 8: Claims Resolutions - Updated 1/1/2024
Appendix I: Online Resources - Updated 1/1/2024
Appendix II: Forms - Updated 1/1/2024
Appendix III: Definitions

Printable PDF of Entire Manual - Updated 7/1/2024