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ced54c98-db41-4a02-b59a-5505a0942bed.aspx
  
GPSCancer™TestingbyNantHealth06.02.5006.02.50Pathology and Laboratory (06)GPS Cancer™ Testing by NantHealthced54c98-db41-4a02-b59a-5505a0942bed5334GPS Cancer™ Testing by NantHealth06.02.505/31/2023 1:00 PM
7/1/2023
1f82c39e-c7a1-49d4-b712-84c801f7121a.aspx
  
HydroxyprogesteroneCaproateInjectionasaTechniquetoReducetheRiskofPretermBirthinHigh-RiskPregnancies08.01.00g08.01.00gPharmacy (08)Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies1f82c39e-c7a1-49d4-b712-84c801f7121a5329Hydroxyprogesterone Caproate Injection as a Technique to Reduce the Risk of Preterm Birth in High-Risk Pregnancies08.01.005/31/2023 10:00 AM
6/30/2023
21cf7389-1ac2-4bb6-870f-bd117bd06fe5.aspx
  
Belantamabmafodotin-blmf(Blenrep)08.01.70b08.01.70bPharmacy (08)Belantamab mafodotin-blmf (Blenrep)21cf7389-1ac2-4bb6-870f-bd117bd06fe55328Belantamab mafodotin-blmf (Blenrep)08.01.705/31/2023 10:00 AM
6/30/2023
3aedbc12-6d64-44cd-af8b-245538c08d35.aspx
  
patisiran(Onpattro®)andvutrisiran(Amvuttra™)08.01.50c08.01.50cPharmacy (08)patisiran (Onpattro®) and vutrisiran (Amvuttra™)3aedbc12-6d64-44cd-af8b-245538c08d355086patisiran (Onpattro®) and vutrisiran (Amvuttra™)08.01.503/14/2023 10:00 AM
6/12/2023
3febd8aa-75a8-4c6a-be5c-5048a128fdb9.aspx
  
InjectableDermalFillersforCosmeticProcedures05.00.62i05.00.62iDME (05)Injectable Dermal Fillers for Cosmetic Procedures3febd8aa-75a8-4c6a-be5c-5048a128fdb95119Injectable Dermal Fillers for Cosmetic Procedures05.00.623/31/2023 1:00 PM
7/1/2023
ab93aadf-f22e-4739-810d-e066c9b70846.aspx
  
CosmeticProcedures12.01.03b12.01.03bMiscellaneous (12)Cosmetic Proceduresab93aadf-f22e-4739-810d-e066c9b708465309Cosmetic Procedures12.01.033/31/2023 11:00 AM
7/1/2023
9bc79317-fbd0-48d3-9c17-98a71ea106c3.aspx
  
eviCoreLabManagement(Independence)06.02.52ac06.02.52acPathology and Laboratory (06)eviCore Lab Management (Independence)9bc79317-fbd0-48d3-9c17-98a71ea106c35346eviCore Lab Management (Independence)06.02.526/1/2023 10:00 AM
{"5347": {"Id":5347,"MPAttachmentLetter":"B","Title":"Procedure Codes Requiring Prepayment Reviews","MPPolicyAttachmentInternalSourceId":7402,"PolicyAttachmentPageName":"77d84dc3-aba8-46c8-b12c-fe6fc6698b0e"},"5348": {"Id":5348,"MPAttachmentLetter":"A","Title":"Procedure Codes Requiring Pre-service and Prepayment Reviews","MPPolicyAttachmentInternalSourceId":7404,"PolicyAttachmentPageName":"ffe67992-36e2-4b42-869e-6819c4b8b7da"},}
7/1/2023
19af820b-40e1-4694-aad5-b0aebf346a94.aspx
  
LaboratoryServicesforMembersEnrolledinHealthMaintenanceOrganization(HMO)orHealthMaintenanceOrganizationPoint-of-Service(HMO-POS)Products00.03.07ak00.03.07akAdministrative (00)Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products19af820b-40e1-4694-aad5-b0aebf346a945322Laboratory Services for Members Enrolled in Health Maintenance Organization (HMO) or Health Maintenance Organization Point-of-Service (HMO-POS) Products00.03.074/21/2023 2:00 PM
{"5323": {"Id":5323,"MPAttachmentLetter":"B2","Title":"SERVICES ELIGIBLE FOR REIMBURSEMENT IN THE OUTPATIENT HOSPITAL LABORATORY","MPPolicyAttachmentInternalSourceId":7221,"PolicyAttachmentPageName":"efdb5c86-58c9-425b-930e-df1535387cc2"},"5324": {"Id":5324,"MPAttachmentLetter":"B1","Title":"SERVICES ELIGIBLE FOR REIMBURSEMENT WHEN PERFORMED IN THE SPECIALIST OFFICE (THIS INCLUDES THE CERTIFIED REGISTERED NURSE PRACTITIONER (CRNP) AND PHYSICIAN ASSISTANT (PA) PRACTICING WITHIN THE SCOPE OF THEIR SPECIALTY)","MPPolicyAttachmentInternalSourceId":7222,"PolicyAttachmentPageName":"da7aeaa2-55fa-48e1-9783-3aa6c3de5eb5"},"5325": {"Id":5325,"MPAttachmentLetter":"A2","Title":"HCPCS CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE","MPPolicyAttachmentInternalSourceId":7223,"PolicyAttachmentPageName":"9bd9e264-b691-4684-add0-787d84ab20aa"},"5326": {"Id":5326,"MPAttachmentLetter":"A1","Title":"CPT CODES INCLUDED IN CAPITATION TO THE PCP'S DESIGNATED LABORATORY SITE","MPPolicyAttachmentInternalSourceId":7224,"PolicyAttachmentPageName":"d1cb83f2-a22c-48f7-94e4-1031607efea8"},}
7/31/2023
0f67d2dd-b927-4f7a-bbad-842856794d67.aspx
  
Luspatercept–aamt(Reblozyl®)08.00.10c08.00.10cPharmacy (08)Luspatercept–aamt (Reblozyl®)0f67d2dd-b927-4f7a-bbad-842856794d675316Luspatercept–aamt (Reblozyl®)08.00.105/22/2023 12:00 PM
8/21/2023
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.