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BCBSGa Reimbursement Policies

3962As 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.  
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)
Bundled Services Coding List
Cancer Treatment Planning and Care Coordination
Claim Editing Overview
Claims Requiring Additional Documentation
Codes that Include moderate sedation
Co-Surgeon/Team Surgeon Services
Documentation and Reporting Guidelines for Applied Behavior Assessments (ABA) and Treatments for Autism Spectrum Disorder – professional
Documentation and Reporting Guidelines for Consultations
Documentation and Reporting Guidelines for Evaluation and Management Services
Documentation Guidelines for Central Nervous system Assessments/Tests
Documentation Guidelines for Psychotherapy Services
Drug Screen Testing
Durable Medical Equipment
Duplicate Reporting of Diagnostic Services
Evaluation and Management Services and Related Modifiers -25 & -57
Expenses Included in Facility Services
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)
Modifiers 59 and XE, XP, XS, and XU – professional
Modifier Rules
Multiple and Bilateral Surgery Processing
Multiple Diagnostic Cardiology Services
Multiple Diagnostic Imaging Procedures
Multiple Diagnostic Ophthalmology Services
Office Place of Service
Once per Lifetime – professional
Overhead Expense For Office Based Surgery and Diagnostic Testing
Pharmaceutical Waste
Physical and Manipulative Maintenance Services
Physician Standby Service
Place of Service
Prolonged Services
Routine Obstetric Services
“Rule of Eight” Reporting Guidelines for Physical Medicine and Rehabilitation Services
Scope of License
Screening Services with Evaluation & Management Services
Sleep Studies and Related Bundled Services & Supplies
Surgical Pathology and Related Prostate Needle Biopsy
Telemedicine and Telehealth Services
Unit Frequency Maximums for Drugs and Biologic Substances
Urgent Care (Coding and Bundled Supplies)
Facility Reimbursement Policies
3D Rendering of Imaging Studies
Body Mass Index Policy
Claims Requiring Additional Documentation Policy
DRG Newborn Inpatient Stays
Emergency Department
Facility Charges Associated with Services within a Surgical Global Period
Facility Drug Testing
Facility Emergency Department
Implant Policy
Neonatal Reimbursement Policy
Observation Services or Hours Billing Policy
Pharmaceutical Waste Policy
Preventable Adverse Events (PAE) Policy
Revenue Code Billing
Robotic Assisted Surgery
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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.