Reference Section
Section 1: Network Overview
Section 2: Network Participation - Updated 7/1/2025
Section 3: Member Engagement
Section 4: Medical Management - Updated 5/27/2025
Section 5: Billing and Reimbursement Guidelines
Section 5.1: General Billing and Reimbursement - Updated 3/24/2025
Section 5.2: After Hours Care
Section 5.3: Ambulance Transport Benefit
Section 5.4: Anesthesia Updated
Section 5.5: Autism Updated
Section 5.6: Behavioral Health Updated
Section 5.7: Code Editing Updated
Section 5.8: Dialysis
Section 5.9: Dietitian
Section 5.10: Drug Eluting Intracoronary Stents
Section 5.11: Drug Screening Assays
Section 5.12: Home Health Agency
Section 5.13: Inpatient Updated
Section 5.14: Inpatient Unbundling Policy - Updated 5/27/2025
Section 5.15: Intra-operative Monitoring Services
Section 5.16: Laboratory - Updated 8/1/2025
Section 5.17: Maternity Care and Delivery
Section 5.18: Multiple Service Reduction for Diagnostic Imaging Services
Section 5.19: Nucleic Acid Probe Services
Section 5.20: Outpatient - Updated 3/24/2025
Section 5.21: Pass Through Billing and Billing for Services Not Rendered
Section 5.22: Place of Service
Section 5.23: Provider Based Billing
Section 5.24: Sleep Study
Section 5.25: Urgent Care Centers
Section 5.26: Fertility Preservation Services - Updated 5/27/2025
Section 5.27: Medical Records Documentation
Section 6: Other Coverage
Section 7: Claims Submission - Updated 7/1/2025
Section 8: Claims Resolutions
Section 9: MS-DRG Type of Service Listing
Appendix I: Online Resources
Appendix II: Forms - Updated 7/1/2025
Appendix III: Definitions
Printable PDF of Entire Manual - Updated 8/1/2025
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