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 BlueChoice HealthPlan Medicaid 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 These policies may be superseded by state, federal or Centers for Medicare & Medicaid Services (CMS) requirements.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 Procedure Terminology (CPT), 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 BlueChoice HealthPlan Medicaid reserves the right to review and revise its policies periodically.
Reimbursement Policy Disclaimer
These policies serve as a guide to assist you in accurate claim submissions and to outline the basis for reimbursement if the service is covered by a member’s BlueChoice HealthPlan Medicaid benefit plan. The determination that a service, procedure, item, etc. is covered under a member’s benefit plan is not a determination that you will be reimbursed. Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis as well as to the member’s state of residence. You must follow proper billing and submission guidelines. You are required to use industry standard, compliant codes on all claim submissions. Services should be filled with CPT codes, HCPCS codes and/or Revenue codes. The codes denote the services and/or procedures performed. The billed code(s) are required to be fully supported in the medical record and/or office notes. Unless otherwise noted within the policy, our policies apply to both participating and nonparticipating providers and facilities.
If appropriate coding/billing guidelines or current reimbursement policies are not followed, BlueChoice HealthPlan Medicaid may:
- Reject or deny the claim
- Recover and/or recoup claim payment
BlueChoice HealthPlan Medicaid reimbursement policies are developed based on nationally accepted industry standards and coding principles. These policies may be superseded by mandates in provider or state contracts, or state, federal or CMS requirements. System logic or setup may prevent the loading of policies into the claims platforms in the same manner as described; however, BlueChoice HealthPlan Medicaid strives to minimize these variations.
BlueChoice HealthPlan Medicaid reserves the right to review and revise its policies periodically when necessary. When there is an update we will publish the most current policy to this site.
Reimbursement Policy Definitions
This list of definitions are standard terms used for the majority of our reimbursement policies.
Reimbursement Policy Categories