Home Administrative Billing & Reimbursement BlueCard® Health and Wellness Medical PEAR portal Pharmacy Products Quality Management

Upcoming changes to Medicare Advantage policies and clinical relationship logic

July 1, 2014

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.

NaviNet® is a registered trademark of NaviNet, Inc., an independent company.


This content was prepared for the Provider News Center and may not be reproduced in any way without the express written permission of Independence Blue Cross. Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association.
Connect with us     Facebook     Twitter     Flickr     YouTube     Walk the Talk    Independence Pinterest    Independence LinkedIn    Independence Instagram Site Map        Anti-Fraud        Privacy Policy        Legal        Disclaimer
© 2023 Independence Blue Cross.
Independence Blue Cross is an independent licensee of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.