Medicaid Reimbursement Policies

We want to assist physicians, facilities and other providers in accurate claims submissions and to outline the basis for reimbursement if the service is covered by a member’s Healthy Blue benefit plan. Keep in mind that determination of coverage under a member's benefit plan does not necessarily ensure reimbursement. These policies may be superseded by state, federal or Centers for Medicare & Medicaid Services (CMS) requirements. Providers and facilities are required to use industry standard codes for claim submissions. Services should be billed with Current Procedural Terminology (CPT) codes, Healthcare Common Procedure Coding System (HCPCS) codes and/or revenue codes. The billed code(s) should be fully supported in the medical record and/or office notes. Industry practices are constantly changing and Healthy Blue reserves the right to review and revise its policies periodically.

reimbursement-policies.js
Name (for use in forms)MarketTitleReimbursement CategoryApproval StatusPlan
LALA_CAID_EpisodesofCare.pdfLADocumentation Standards for Episodes of CareReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_EPSDT.pdfLAEarly and Periodic Screening, Diagnostic, and Treatment (EPSDT)PreventionApprovedMedicaid
LALA_CAID_FacilityTakehomeDME.pdfLAFacility Take-Home DME and Medical SuppliesDME and SuppliesApprovedMedicaid
LALA_CAID_Hysterectomy.pdfLAHysterectomy SurgeryApprovedMedicaid
LALA_CAID_InpatientReadmission.pdfLAInpatient ReadmissionsFacilitiesApprovedMedicaid
LALA_CAID_Modifer24.pdfLAModifier 24: Unrelated Evaluation and Management Service by the Same Physician During the Postoperative PeriodCodingApprovedMedicaid
LALA_CAID_Modifer66.PDFLAModifier 66: Surgical TeamsCodingApprovedMedicaid
LALA_CAID_Modifier25.pdfLAModifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other ServiceCodingApprovedMedicaid
LALA_CAID_Modifier26andTC.pdfLAModifier 26 and TC: Professional and Technical ComponentCodingApprovedMedicaid
LALA_CAID_Modifier57.pdfLAModifier 57: Decision for SurgeryCodingApprovedMedicaid
LALA_CAID_Modifier63.pdfLAModifier 63: Procedure Performed on Infants less than 4 kgCodingApprovedMedicaid
LALA_CAID_ModifiersLTRT.pdfLAModifiers LT and RT: Left Side/Right Side ProceduresCodingApprovedMedicaid
LALA_CAID_ModifierUsuage.pdfLAModifier UsageCodingApprovedMedicaid
LALA_CAID_MultipleandBilateralSurgery.pdfLAMultiple and Bilateral Surgery: Professional and Facility ReimbursementCodingApprovedMedicaid
LALA_CAID_MultpleRadiologyPaymentRdctn.pdfLAMultiple Radiology Payment Reduction RadiologyApprovedMedicaid
LALA_CAID_PortableMobileHandheldRadiology.pdfLAPortable/Mobile/Handheld Radiology RadiologyApprovedMedicaid
LALA_CAID_PreadmissionServicesInpatient.pdfLAPreadmission Services for Inpatient StaysFacilitiesApprovedMedicaid
LALA_CAID_PreventativeandSickVisits.pdfLAPreventive Medicine and Sick Visits on the Same Day Evaluation and ManagementApprovedMedicaid
LALA_CAID_ProofofTimelyFiling.pdfLAProof of Timely FilingReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ProsteticandOrthoDev.pdfLAProsthetic and Orthotic Devices Prosthetics and OrthoticsApprovedMedicaid
LALA_CAID_ReimburItemsunderWarr.pdfLAReimbursement for Items Under WarrantyReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ReimbursementofSanctionedOptOut.pdfLAReimbursement of Sanctioned and Opt-Out ProvidersReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ReimbursofObsoletCodes.pdfLAReimbursement of Services with Obsolete CodesCodingApprovedMedicaid
LALA_CAID_ScopeofPractice.pdfLAScope of PracticeReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_SplitCareSurgicalMod.pdfLASplit-Care Surgical ModifiersCodingApprovedMedicaid
LALA_CAID_Sterilization.pdfLASterilizationSurgeryApprovedMedicaid
LALA_CAID_TransportationServices.pdfLATransportation Services: Ambulance and Nonemergent Transport TransportationApprovedMedicaid
LALA_CAID_VFCProgram.pdfLAVaccines for Children (VFC) Program PreventionApprovedMedicaid
LALA_CAID_Abortion.pdfLAAbortionSurgeryApprovedMedicaid
LALA_CAID_AnethesiaServices.pdfLAProfessional Anesthesia ServicesAnesthesiaApprovedMedicaid
LALA_CAID_AssistantatSurgery.pdfLAAssistant at Surgery (Modifiers 80/81/82/AS)CodingApprovedMedicaid
LALA_CAID_ClaimsRequiringAddDoc.pdfLAClaims Requiring Additional DocumentationReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ClaimsSubmissionFac.pdfLAClaims Submission — Required Information for FacilitiesReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ClaimsSubmissionRequiredInd.pdfLAClaims Submission — Required Information for Professional ProvidersReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_ClaimsTimelyFiling.pdfLAClaims Timely FilingReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_CodeClinicalEditing.pdfLACode and Clinical Editing GuidelinesReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_DistinctProceduralServices.pdfLAReimbursement for Reduced and Discontinued ServicesCodingApprovedMedicaid
LALA_CAID_DrugsInjectableLimits.pdfLADrugs and Injectable LimitsDrugsApprovedMedicaid
LALA_CAID_EligibleBilledCharges.pdfLAEligible Billed ChargesReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_EmergServicesNonPAR.pdfLAEmergency Services: Nonparticipating Providers and FacilitiesReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_RP_MaternityServices.pdfLAMaternity ServicesSurgeryApprovedMedicaid
LALA_CAID_RP_MultDelivServ.pdfLAMultiple Delivery ServicesSurgeryApprovedMedicaid
LALA_CAID_RP_RoboticAssistSurg.pdfLARobotic Assisted SurgerySurgeryApprovedMedicaid
LALA_CAID_RP_Modifier62_CoSurgeons.pdfLAModifier 62: Co-SurgeonsCodingApprovedMedicaid
LALA_CAID_ReimbofClaimswithCharge.pdfLAReimbursement of Claims with Charge DiscrepanciesReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_RiemforMaxUnits.pdfLA Reimbursement for Maximum Units Per DayReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_MedicalRecalls.pdfLAMedical RecallsReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_CorrectedClaims.pdfLACorrected ClaimsReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_DupSubServices.pdfLADuplicate or Subsequent Services on the Same Date of ServiceReimbursement Administration - GeneralApprovedMedicaid
LALA_CAID_FacilityTakeHome.pdfLAFacility Take-Home DrugsDrugsApprovedMedicaid
LALA_CAID_Modifier91.pdfLA Modifier 91: Repeat Clinical Diagnostic Laboratory TestCodingApprovedMedicaid
LALA_CAID_Modifier22.pdfLAModifier 22: Increased Procedural ServiceCodingApprovedMedicaid
LALA_CAID_Mod78.pdfLAModifier 78: Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative PeriodCodingApprovedMedicaid
LALA_CAID_Mod77.pdfLAModifier 77: Repeat Procedure by Another Physician or Other Qualified Health Care ProfessionalCodingApprovedMedicaid
LALA_CAID_DXDRGComputation.pdfLA Diagnoses Used in DRG ComputationCodingApprovedMedicaid
LALA_CAID_DMEMods.pdfLA DME Modifiers for New, Rented, and Used EquipmentCodingApprovedMedicaid
LALA_CAID_Mod76.pdfLAModifier 76: Repeat Procedure by the Same PhysicianCodingApprovedMedicaid
LALA_CAID_LocumTenensPhysicians.pdfLALocum Tenens Physicians/Fee-for-Time CompensationReimbursement Administration - GeneralApprovedMedicaid
LALA_RP_UnlistedUnspecifiedMiscCodes.pdfLAUnlisted, Unspecified or Miscellaneous CodesCodingApprovedMedicaid
LALA_RP_GlobalSurgical.pdfLAGlobal Surgical Package for Professional ProvidersSurgeryApprovedMedicaid
LALA_CAID_DMERenttoPurchase.pdfLADurable Medical Equipment (Rent to Purchase)DME and SuppliesApprovedMedicaid
LALA_CARE_RP_Abortion.pdfLAAbortionSurgeryApprovedMedicare
LALA_CARE_RP_AssistantatSurgery.pdfLAAssistant at Surgery Guidelines (Modifier 80/81/82/AS)CodingApprovedMedicare
LALA_CARE_RP_ChargeDiscrepanciesClaims.pdfLAReimbursement of Claims with Charge DiscrepanciesReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ClaimsRequiringAdditionalDocs.pdfLAClaim Requiring Additional DocumentationReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ClaimsSubReqInfoFacilities.pdfLAClaim Submission – Required Information for Facilities (UB-92)Reimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ClaimsSubReqInfoProProviders.pdfLAClaim Submission – Required Information Professional (CMS 1500)Reimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ClaimsTimelyFiling.pdfLAClaims Timely FilingReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_CodeandClinicalEditingGuidelines.pdfLACode and Clinical Editing GuidelinesReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_Consultations.pdfLAConsultationsEvaluation and ManagementApprovedMedicare
LALA_CARE_RP_CorrectedClaims.pdfLACorrected ClaimsReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_DiagnosisUsedinDRGComputation.pdfLADiagnoses Used for DRG ComputationCodingApprovedMedicare
LALA_CARE_RP_Disclaimer.pdfLAReimbursement Policy DisclaimerReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_DistinctProceduralServices.pdfLADistinct Procedural Services (Modifiers 59, XE, XP, XS, XU)CodingApprovedMedicare
LALA_CARE_RP_DMEModifiersNewRentedUsed.pdfLADME Modifiers for New, Rented, and Used EquipmentCodingApprovedMedicare
LALA_CARE_RP_DMERenttoPurchase.pdfLADurable Medical Equipment (Rent to Purchase)DME and SuppliesApprovedMedicare
LALA_CARE_RP_DocumentationStandardsEpisodesofCare.pdfLADocumentation Standards for Episodes of CareReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_DRG_NewbornInpatientStays.pdfLADRG Newborn Inpatient StaysFacilitiesApprovedMedicare
LALA_CARE_RP_DrugScreenTesting.pdfLADrug Screen TestingLaboratoryApprovedMedicare
LALA_CARE_RP_DrugsInjectableLimits.pdfLADrugs and Injectable LimitsDrugsApprovedMedicare
LALA_CARE_RP_DuplicateSubServicesSameDay.pdfLADuplicate Services on the Same Date of ServiceReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_EligibleBilledCharges.pdfLAEligible Billed ChargesReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_EmergencyDepartmentLevelofEMServices.pdfLAEmergency Department: Level of E&M ServicesFacilitiesApprovedMedicare
LALA_CARE_RP_ERServiceforNonParProvidersFacilities.pdfLAEmergency Services: Nonparticipating Providers and FacilitiesReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_FacilityTakeHomeDME.pdfLAFacility Take-Home DME and Medical SuppliesDME and SuppliesApprovedMedicare
LALA_CARE_RP_GlobalSurgicalPackageProProviders.pdfLAGlobal Surgical Package for Professional ProvidersSurgeryApprovedMedicare
LALA_CARE_RP_Hysterectomy.pdfLAHysterectomySurgeryApprovedMedicare
LALA_CAID_RP_InpatientFacilityTransfers.pdfLADRG Inpatient Facility TransferFacilitiesApprovedMedicaid
LALA_CARE_RP_InpatientReadmissions.pdfLAInpatient ReadmissionsReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ItemsUnderWarranty.pdfLAReimbursement for Items under WarrantyReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_LocumTenens.pdfLALocum Tenens PhysiciansReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_MaternityServices.pdfLAMaternity ServicesSurgeryApprovedMedicare
LALA_CARE_RP_MaximumUnitsPerDay.pdfLAReimbursement for Maximum Units Per DayReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_MedicalRecalls.pdfLAMedical RecallsReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_Modifier22.pdfLAModifier 22: Unusual Procedural ServiceCodingApprovedMedicare
LALA_CARE_RP_Modifier24.pdfLAModifier 24: Unrelated E&M ServiceCodingApprovedMedicare
LALA_CARE_RP_Modifier25.pdfLAModifier 25 - Significant Separate E&M ServicesCodingApprovedMedicare
LALA_CARE_RP_Modifier26.pdfLAModifier 26 and TC: Professional and Technical ComponentCodingApprovedMedicare
LALA_CARE_RP_Modifier57DecisionforSurgery.pdfLAModifier 57: Decision for SurgeryCodingApprovedMedicare
LALA_CARE_RP_Modifier62.pdfLAModifier 62: Co-SurgeonsCodingApprovedMedicare
LALA_CARE_RP_Modifier63.pdfLAModifier 63: Procedure on Infants less than 4kgCodingApprovedMedicare
LALA_CARE_RP_Modifier66SurgicalTeams.pdfLAModifier 66: Surgical TeamCodingApprovedMedicare
LALA_CARE_RP_Modifier76.pdfLAModifier 76: Repeat Procedure by Same PhysicianCodingApprovedMedicare
LALA_CARE_RP_Modifier77.pdfLAModifier 77: Repeat Procedure by Another PhysicianCodingApprovedMedicare
LALA_CARE_RP_Modifier78.pdfLAModifier 78: Return to OR for Related Procedure PostOpCodingApprovedMedicare
LALA_CARE_RP_Modifier91.pdfLAModifier 91: Repeat Clinical Diagnostic Laboratory TestCodingApprovedMedicare
LALA_CARE_RP_ModifierLTRTProcedures.pdfLAModifier LT/RT: Left Side/Right Side ProceduresCodingApprovedMedicare
LALA_CARE_RP_ModifierUsage.pdfLAModifier UsageCodingApprovedMedicare
LALA_CARE_RP_MultipleBilateralSurgery.pdfLAMultiple and Bilateral Surgery – Professional and Facility ReimbursementCodingApprovedMedicare
LALA_CARE_RP_MultipleDeliveryServices.pdfLAMultiple Delivery ServicesSurgeryApprovedMedicare
LALA_CARE_RP_MultipleRadiologyPaymentReduction.pdfLAMultiple Radiology Payment ReductionRadiologyApprovedMedicare
LALA_CARE_RP_PortableMobileHandheldRadiology.pdfLAPortable/Mobile/Handheld RadiologyRadiologyApprovedMedicare
LALA_CARE_RP_PreadmissionServicesforInpatientStays.pdfLAPreadmission Services for Inpatient StaysFacilitiesApprovedMedicare
LALA_CARE_RP_PreventiveMedSameDaySickVisits.pdfLAPreventive Medicine and Sick Visits on Same DayEvaluation and ManagementApprovedMedicare
LALA_CARE_RP_ProfessionalAnesthesiaServices.pdfLAAnesthesia Professional ServicesAnesthesiaApprovedMedicare
LALA_CARE_RP_ProstheticOrthoticDevices.pdfLAProsthetic and Orthotic DevicesProsthetics and OrthoticsApprovedMedicare
LALA_CARE_RP_ReducedDiscontinuedServices.pdfLAReimbursement for Reduced and Discontinued ServicesCodingApprovedMedicare
LALA_CARE_RP_ReqsforDocsofProofofTimelyFiling.pdfLADocumentation Required for Proof of Timely FilingReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_RoboticAssistedSurgery.pdfLARobotic Assisted SurgerySurgeryApprovedMedicare
LALA_CARE_RP_SanctionedOptOutProviders.pdfLAReimbursement of Sanctioned and Opt-Out ProvidersReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ScopeofPractice.pdfLAScope of PracticeReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_ServiceswithObsoleteCodes.pdfLAReimbursement of Services with Obsolete CodesCodingApprovedMedicare
LALA_CARE_RP_SiteofServicePaymentDifferential.pdfLASite of Service Payment Differential - ProfessionalReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_SplitCareSurgicalModifiers.pdfLASplit-Care Surgical ModifiersCodingApprovedMedicare
LALA_CARE_RP_Sterilization.pdfLASterilizationSurgeryApprovedMedicare
LALA_CARE_RP_TransportationServicesAmbulanceNonEmergent.pdfLATransportation Services: Ambulance and Nonemergent TransportTransportationApprovedMedicare
LALA_CARE_RP_UnlistedUnspecifiedMiscCodes.pdfLAUnlisted, Unspecified or Miscellaneous CodesCodingApprovedMedicare
LALA_CAID_DistinctProceduralServices59XEXPXSXU.pdfLADistinct Procedural Services (Modifiers 59, XE, XP, XS, XU)CodingApprovedMedicaid
LALA_CAID_NursePractitionerandPAServices.pdfLANurse Practitioner and Physician Assistant ServicesReimbursement Administration - GeneralApprovedMedicaid
LALA_CARE_RP_PreventableAdverseEvents.pdfLAPreventable Adverse EventsReimbursement Administration - GeneralApprovedMedicare
LALA_CARE_RP_NursePracPhysicianAsstServices.pdfLANurse Practitioner and Physician Assistant ServicesReimbursement Administration - GeneralApprovedMedicare