Effective January 1, 2015, we are introducing changes
related to the application of medical and claim payment policies, as well as
clinical relationship logic, for IBC?s Medicare Advantage business.
Policy changes
Medical and claim payment policies that currently apply to both commercial
and Medicare Advantage business will be
separated into two unique policy portfolios: one for Medicare Advantage
business and one for commercial business.
The new Medicare Advantage policy portfolio will become effective January 1,
2015; notifications for these policies
will be available on the IBC Medical Policy Portal by October 1, 2014. This
policy portfolio will be based on Medicare
coverage guidance as well as additional IBC medical and claim payment policy
determinations.
Note: The existing policy portfolio will continue to apply to
commercial business.
Clinical relationship logic (procedure code-to-procedure code edits)
Effective January 1, 2015, the following will be applied to claims submitted
on the CMS-1500 claim form or through the
837P transaction for Medicare Advantage HMO and PPO members:
- Medicare's National Correct Coding Initiative (NCCI) editing;
- other clinical relationship logic, which is based on procedure code editing
standards.
For more information
Additional information about these changes will be provided in future
editions of Partners in Health UpdateSM.
Stay up to date on policy activity by visiting our Medical Policy Portal. You can also view policy activity
using the NaviNet® web portal by selecting Reference
Tools from the Plan Transactions menu, then Medical Policy. Be
sure to check back often, as the site is updated frequently.
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