Reimbursement Methodology for Non-Participating Providers

Policy No: 135
Originally Created: 01/01/2018
Section: Administrative
Last Reviewed: 12/01/2023
Last Revised: 12/01/2023
Approved: 12/14/2023
Effective: 01/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

This policy applies to Non-Participating outpatient hospitals, ambulatory surgical centers (ASCs), birth centers, outpatient behavioral health treatment facilities, independent laboratories, physicians and other qualified health care professionals.

Note: Certain NonPar payment methodologies are not applicable to Medicare Advantage claims.

Non-Participating (NonPar) Provider
A provider who has not entered into a contractual agreement with our health plan for the member's product. Also referred to as Out-of-Network Provider.

(See Policy Cross References for additional definitions)

Claims submitted by NonPar providers will be processed according to the NonPar payment methodology in place at the time of service. Claims may be subject to, but are not limited to, the following:

• Bundled services may include the application of, but are not limited to, the following:
  • National Correct Coding Initiative (NCCI)
  • Correct Code Editor (CCE) Code Pairs (Not applicable to Medicare Advantage)
  • ClaimsXten™ Unbundled Code Pairs (Not applicable to Medicare Advantage)
  • Incidental Unlisted Codes
• Clinical Edits may include, but are not limited to the following:
  • Non-Reimbursable Services
  • Unlisted Code Review
  • Investigational Denials (Not applicable to Medicare Advantage)
  • Not Medically Necessary Denials
  • Cosmetic Denials (Not applicable to Medicare Advantage)
  • Benefit Denials
• National Physician Fee Schedule Relative Value File (NPFSRVF) pricing rules including, but are not limited to, the following:
  • Procedure Code Status Indicators
  • Global Periods
  • Modifier Pricing, including:
    • Professional/Technical Component
    • Multiple Service Reduction (MSR)
    • Multiple Procedure Pricing Reduction (MPPR) (Applicable to Medicare Advantage)
    • Bilateral Pricing
    • Assistant Surgeon Pricing
    • Co-Surgeon, Team Surgeon Pricing
• ClaimsXtenTM Rules
• Medically Unlikely Edits (MUEs)
• Integrated Outpatient Code Editor (I/OCE) Clinical edits
• Inclusive Facility Fee Services (i.e., ASCs)
• Correct Coding Validation Audits
• Medical Policies, Reimbursement Policies and Administrative Manual
• Reimbursement at the lesser of billed charges or the NonPar reimbursement methodology allowed amount.
• Freestanding ASC payment methodology is based on Centers for Medicare & Medicaid Services (CMS) ASC payment system, as well as CMS Outpatient Prospective Payment System (OPPS) with our health plans modifications.
• Outpatient Hospital payment methodology is based on CMS Outpatient Prospective Payment System (OPPS)
• The Federal No Surprises Act (NSA). Reimbursement will be paid at the Qualified Payment Amount (QPA). (Not applicable to Medicare Advantage)

• The Washington Balance Billing Protection Act (BBPA). Reimbursement will be paid at the Commercially Reasonable Rate (CRR). (Not applicable to Medicare Advantage)

Centers for Medicare & Medicaid Services (CMS), OCE Purpose

Centers for Medicare & Medicaid Services (CMS), Pub 100-04 Medicare Claims Processing

Current Procedural Terminology (CPT®), American Medical Association

National Ambulatory Surgical Center Fee Schedule, Centers for Medicare & Medicaid Services (CMS)

National Physician Fee Schedule Relative Value File, Centers for Medicare & Medicaid Services (CMS)

NCCI Policy Manual for Medicare Services, current version, Chapter 1, General Correct Coding Policies

WA Balance Billing Protection Act (RCW 48.49.160)

Federal No Surprises Act (86 Fed. Reg. 36872, 36881

Global Days

Bundling Edits

Non-Reimbursable Services

Incidental Procedures

Medicare-Based Fee Effective Dates

Maximum Daily Units

Ambulance Guidelines

Implants, Implant Components, Medical and Surgical Supplies for all Procedures

Correct Coding Guidelines

Modifier 51 and Multiple Procedure Logic

Modifier 25; Significant Separately Identifiable E&M Service

Modifiers 59, XE, XP, XS, XU; Distinct Procedural Service

Modifier 26; Professional Component, Modifier TC; Technical Component

Modifier 50; Bilateral Procedure

Modifiers 80, 81, 82, AS; Assistant at Surgery

Modifier 62; Two Surgeons/Co-Surgeons

Modifier 66; Surgical Team