Professional Provider Office Manual 2026

Reference Section - Updated 1/1/2026
Section 1: Network Overview - Updated 1/1/2026
Section 2: Network Participation - Updated 1/1/2026
Section 3: Member Engagement
Section 4: Medical Management - Updated 1/1/2026
Section 5: Billing and Reimbursement Guidelines - Updated 1/1/2026
Section 5.1 General Billing - Updated 1/1/2026
Section 5.2 Acupuncture
Section 5.3 After Hours Care
Section 5.4 Ambulance Transport Benefit
Section 5.5 Anesthesia
Section 5.6 Autism - Updated 1/1/2026
Section 5.7 Behavioral Health - Updated 1/1/2026
Section 5.8 Chiropractic and Physical Medicine Services - Updated 1/1/2026
Section 5.9 Code Editing
Section 5.10 Concierge Medicine - Updated 1/1/2026
Section 5.11 Dialysis
Section 5.12 Dietitian
Section 5.13 Drug Screening Assays
Section 5.14 Durable Medical Equipment and Supplies - Updated 1/1/2026
Section 5.15 Evaluation and Management Services
Section 5.16 Home Health Agency
Section 5.17 Incident to
Section 5.18 Infusion Therapy - Updated 1/1/2026
Section 5.19 In-Office Procedures
Section 5.20 Intra-operative Monitoring Services
Section 5.21 Laboratory - Updated 1/1/2026
Section 5.22 Maternity Care and Delivery - Updated 1/1/2026
Section 5.23 Medication Substitution
Section 5.24 Modifiers
Section 5.25 Multiple Procedures
Section 5.26 Multiple Service Reduction for Diagnostic Imaging Services
Section 5.27 Nasal Endoscopy Procedures
Section 5.28 Nucleic Acid Probe Services
Section 5.29 Nurse Practitioner and Physician Assistant Services
Section 5.30 Ordering/Referring Provider Requirements
Section 5.31 Pass-through Billing and Billing for Services Not Rendered
Section 5.32 Place of Service
Section 5.33 Provider Based Billing
Section 5.34 Rural Health Clinic and Federally Qualified Health Clinic
Section 5.35 Sleep Study
Section 5.36 Specialty Pharmacy
Section 5.37 Telemedicine/Telehealth - Updated 1/1/2026
Section 5.38 Urgent Care Centers - Updated 1/1/2026
Section 5.39 Colonoscopy and Upper Gastrointestinal Endoscopy MPR
Section 5.40 Pharmaceutical Waste
Section 5.41 Mass Immunizers
Section 5.42 Digital Health
Section 5.43 Fertility Preservation Services
Section 5.44 Medical Record Documentation - Updated 1/1/2026
Section 5.45 Dental Billing
Section 5.46 Speech Therapy - Updated 1/1/2026
Section 5.47 Ambulatory Surgery Centers
Section 5.48 HIV Pre-exposure Prophylaxis
Section 5.49 Breast Feeding and Lactation Services - New 1/1/2026
Section 5.50 Clinical Trials - New 1/1/2026
Section 6: Other Coverage
Section 7: Claims Submission - Updated 1/1/2026
Section 8: Claims Resolutions - Updated 12/1/2025
Appendix I: Online Resources - Updated 1/1/2026
Appendix II: Forms - Updated 1/1/2026
Appendix III: Definitions - Updated 1/1/2026

Printable PDF of Entire Manual - Updated 1/1/2026