Health care claims payment policies are guidelines used to assist in administering payment rules based on generally accepted principles of correct coding. They are used to help identify whether health care services are correctly coded for reimbursement. Each payment rule is sourced by a generally accepted coding principle. They include, but are not limited to claims processing guidelines referenced by the Centers for Medicare and Medicaid Services (CMS), Publication 100-04, Claims Processing Manual for physicians/non-physician practitioners, the CMS National Correct Coding Initiative policy manual (procedure-to-procedure coding combination edits and medically unlikely edits), Current Procedural Technology guidance published by the American Medical Association (AMA) for reporting medical procedures and services, health plan clinical policies based on the appropriateness of health care and medical necessity, and at times state-specific claims reimbursement guidance.
All policies found in the SilverSummit Healthplan Payment Policy Manual apply with respect to SilverSummit Healthplan members. Policies in the SilverSummit Healthplan Payment Policy Manual may have either a SilverSummit Healthplan or a “Centene” heading. In addition, SilverSummit Healthplan may from time to time employ a vendor that applies payment policies to specific services; in such circumstances, the vendor’s guidelines may also be used to determine whether a service has been correctly coded. Other policies (e.g., clinical policies) or contract terms may further determine whether a technology, procedure or treatment that is not addressed in the Payment Policy Manual is payable by SilverSummit Healthplan.
The Payment Policy Manuals may be accessed through the link below. This site allows you to:
Search by keyword by selecting the “Search” tab in the upper left hand corner and enter a key word, or Browse by topic by selecting the “Catalog” tab in the upper left hand corner and click on the + sign next to the Payment Policy icon.
If you have any questions regarding these policies, please contact Member Services and ask to be directed to the Medical Management department.