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Medical Policy, Clinical UM Guidelines, and Pre-Cert Requirements

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Medicare Advantage Reimbursement Policies

Standard terms used within the majority of our reimbursement policies. For specific policy-related definitions, please view the individual policy. Provider and/or state contract definitions supersede the definitions listed within the document above. 
Assistant at Surgery
Claims Requiring Additional Documentation
Claims Submissions: Facilities
Claims Submissions: Professionals
Claims Timely Filing
Code and Clinical Editing
Corrected Claims
Diagnoses Used in DRG Computation
Distinct Procedural Services (Modifiers 59, XE, XP, XU)
Documentation Standards
DRG Newborn Inpatient Stays
Drug and Injectable Limits
Duplicate or Subsequent Services on Same Date
Durable Medical Equipment (Rent to Purchase)
Durable Medical Equipment Modifiers for New, Rented, and Used Equipment
Emergency Services: Non-Contracting Facilities and Providers
Facility Take-Home DME and Medical Supplies
Facility Take-Home Drugs
Global Surgical Package
Inpatient Facility Transfers
Inpatient Readmissions
Locum Tenens Physicians
Maternity Services
Medical Recalls
Modifier 22
Modifier 24
Modifier 25
Modifier 26 TC
Modifier 57
Modifier 62
Modifier 63
Modifier 66
Modifier 76
Modifier 77
Modifier 78
Modifier 91
Modifier LT/RT
Modifier Usage
Multiple Bilateral Surgeries
Multiple Delivery Services
Multiple Radiology Payment Reductions
Other Provider Preventable Conditions
Portable/Mobile/Handheld Radiology
Preadmission Services
Present on Admission Indicator for Healthcare Acquired Conditions
Preventative Medicine and Sick Visits on Same Day
Professional Anesthesia Services
Proof of Timely Filing
Prosthetics and Orthotics
Reduced and Discontinued Services
Reimbursement of Claims with Charge Discrepancies
Reimbursement for Eligible Billed Charges
Reimbursement for Items under Warranty
Reimbursement for Maximum Units Per Day
Reimbursement of Obsolete Codes
Reimbursement of Sanctioned and Opt-Out Providers
Robotic Assisted Surgery
Scope of Practice
Site of Service Payment Differential
Split Care Modifiers
Transportation Services: Ambulance and Non-Emergent Transport
Unlisted or Miscellaneous Codes
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