Professional Provider Office Manual 2025

Reference Section - Updated 1/1/2025
Section 1: Network Overview - Updated 1/1/2025
Section 2: Network Participation - Updated 1/1/2025
Section 3: Member Engagement
Section 4: Medical Management - Updated 1/1/2025
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2025
Section 5.1 General Billing - Updated 1/1/2025
Section 5.2 Acupuncture
Section 5.3 After Hours Care
Section 5.4 Ambulance Transport Benefit
Section 5.5 Anesthesia - Updated 1/1/2025
Section 5.6 Autism
Section 5.7 Behavioral Health
Section 5.8 Chiropractic and Physical Medicine Services
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 1/1/2025
Section 5.15 Evaluation and Management Services - Updated 1/1/2025
Section 5.16 Home Health Agency
Section 5.17 Incident to
Section 5.18 Infusion Therapy
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services
Section 5.21 Laboratory - Updated 1/1/2025
Section 5.22 Maternity Care and Delivery
Section 5.23 Medication Substitution
Section 5.24 Modifiers - Updated 1/1/2025
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 1/1/2025
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
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study - Updated 1/1/2025
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth - Updated 1/1/2025
Section 5.38 Urgent Care Centers
Section 5.39 Colonoscopy and Upper Gastrointestinal Endoscopy MPR - Updated 1/1/2025
Section 5.40 Pharmaceutical Waste
Section 5.41 Mass Immunizers
Section 5.42 Digital Health
Section 5.43 Fertility Preservation Services
Section 5.44 Medical Record Documentation - Updated 1/1/2025
Section 5.45 Dental Billing
Section 6: Other Coverage
Section 7: Claims Submission - Updated 1/1/2025
Section 8: Claims Resolutions - Updated 1/1/2025
Appendix I: Online Resources
Appendix II: Forms - Updated 1/1/2025
Appendix III: Definitions - Updated 1/1/2025

Printable PDF of Entire Manual - Updated 1/1/2025