Access our secured site
LoginLogin
Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

View requirements for Local Plan and BlueCard Out-of-Area members.

Search our online provider directory when you need a doctor, hospital, or other health care provider.

BCBSGa Reimbursement Policies

PW_E213664
As part of BCBSGa's ongoing commitment to transparency in our relationships with our participating physicians and other participating healthcare professional providers, and to promote a better understanding of the reimbursement rules and claims editing logic that may impact payment for specific services covered under the applicable member's benefit plan, we have listed below BCBSGa's core reimbursement policies.  
Please keep in mind that BCBSGa's reimbursement policies are only one of the many factors that impact payment. Payment is also subject to and impacted by the scope of benefits included in the applicable member's benefit plan, state and federal law, BCBSGa's medical policies or clinical guidelines, the terms of the participating provider contracts and the provider manual. BCBSGa's medical policies, clinical guidelines and BCBSGa's provider manual can be found on this provider website.  
In the event of a conflict between a reimbursement policy described below and the applicable member's benefit contract or the terms of the participating provider contract, these documents, along with applicable state and federal law, shall control. The appearance of a service, item or procedure on the below list indicates that BCBSGa has a reimbursement policy that covers that particular service but it does not mean that the particular item or procedure is a covered service, or medically necessary, for that member; nor is it a guarantee for payment.  
Limitations
These reimbursement policies are current as of the date of this document. BCBSGa revises reimbursement policies from time to time and publishes updates in our provider newsletter. Every effort will be made to update this document as new policies are created or existing policies are added.
As the owner of these reimbursement policies, BCBSGa has the sole right to interpret them. If you find any reimbursement policy unclear, please let us know so that we may take the opportunity to clarify our policies.
BCBSGa's reimbursement policies do not determine how BCBSGa affiliates or other BlueCross BlueShield plans reimburse providers under BlueCard plans. BCBSGa's reimbursement policies apply to BCBSGa only.
Certain reimbursement policies may not apply to claims submitted by non-participating providers for Medicare Advantage members (which follow CMS rules) or FEHB enrollees. Reimbursement policies will be applied to claims submitted by participating providers for Medicare Advantage members.
 
Professional Reimbursement Policies
3D Rendering of Imaging Studies
After Hours Policy
Assistant Surgeon Services
Bundled Services and Supplies (EPRP - 0008)
Cancer Treatment Planning and Care Coordination
Claim Editing Overview
Co-Surgeon/Team Surgeon Services
Documentation and Reporting Guidelines for Consultations
Documentation and Reporting Guidelines for Evaluation and Management Services
Documentation Guidelines for Central Nervous system Assessments/Tests
Durable Medical Equipment
Evaluation and Management Services and Related Modifiers -25 & -57
Frequency Editing
Global Surgery
Health and Behavior Assessment/Intervention
“Incident to” Services
Injectable Substances with Injection Services
Injection & Infusion Administration and Related Services & Supplies
Laboratory and Venipuncture Services
Moderate Sedation
Modifier 22 (Increased Procedural Services)
Modifier 59 (Distinct Procedural Service)
Modifier Rules
Multiple and Bilateral Surgery Processing
Multiple Diagnostic Imaging Procedures
Office Place of Service
Overhead Expense For Office Based Surgery and Diagnostic Testing
Pharmaceutical Waste
Physical and Manipulative Maintenance Services
Physician Standby Service
Place of Service
Prolonged Services
Qualitative Drug Screen Testing
Routine Obstetric Services
Rule of Eight
Screening Services with Evaluation & Management Services
Sleep Studies and Related Bundled Services & Supplies
Surgical Pathology and Related Prostate Needle Biopsy
Telemedicine and Telehealth Services
Urgent Care (Coding and Bundled Supplies)
 
Facility Reimbursement Policies
3D Rendering of Imaging Studies
Emergency Department
Implant Policy
Observation Services or Hours Billing Policy
Preventable Adverse Events (PAE) Policy
Robotic Assisted Surgery
© 2014 BlueCross BlueShield of Georgia
Blue Cross and Blue Shield of Georgia, Inc. and Blue Cross Blue Shield Healthcare Plan of Georgia, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.