The Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition.
This policy applies to professional and outpatient facility claims.
If procedure codes identified within the National Correct Coding Initiative (NCCI) edit pair file are reported for the same individual, on the same date of service, by the same provider, the Company will apply the associated NCCI edit for those Procedure-to-Procedure (PTP) code pairs.
Modifiers may be appended to PTP code pairs, when appropriate, based on the Centers for Medicare and Medicaid Services (CMS) NCCI modifier indicators for each PTP code pair edit.
PTP code pairs designated by CMS with an NCCI modifier indicator of 0 (zero) are not eligible to be reimbursed separately when reported on the same date of service, for the same member, when performed by the same provider. The NCCI edit identified in the CMS NCCI file for these procedure code pairs will be applied by the Company regardless of the presence of a modifier.
PTP code pairs designated by CMS with an NCCI modifier indicator of 1, when clinically appropriate and reported with an appropriate modifier, are eligible for separate reimbursement consideration by the Company.
Refer to the CMS NCCI file for PTP code pair edits and the associated modifier indicators.
The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the professional provider's office, hospital, nursing home, home health agencies, therapies, and test reports.
The Company may conduct pre-payment reviews and post-payment audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.